Healthcare Provider Details

I. General information

NPI: 1730141938
Provider Name (Legal Business Name): DARRYL SANDIDGE PA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/04/2006
Last Update Date: 10/27/2022
Certification Date: 10/25/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1260 N ARENDELL AVE
ZEBULON NC
27597-8730
US

IV. Provider business mailing address

PO BOX 602195
CHARLOTTE NC
28260-2195
US

V. Phone/Fax

Practice location:
  • Phone: 919-235-1965
  • Fax: 919-235-1326
Mailing address:
  • Phone: 919-350-8991
  • Fax: 919-350-7687

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QU0200X
TaxonomyUrgent Care Clinic/Center
License Number0010-06204
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA9102240
License Number StateFL
# 3
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number0010-06204
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: