=====================================================
General NPI Number Information
=====================================================
NPI Number | 1356433171
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JOHN SARDELLA PA-C
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/29/2006
-----------------------------------------------------
Last Update Date | 12/03/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4654 LONG BEACH RD SE
-----------------------------------------------------
City | SOUTHPORT
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28461-8799
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 910-457-9564
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 10250 TIMBER RIDGE CT SE
-----------------------------------------------------
City | LELAND
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28451-8536
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 910-520-1514
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363AM0700X
-----------------------------------------------------
Taxonomy Name | Medical Physician Assistant
-----------------------------------------------------
License Number | 101496
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------