=====================================================
General NPI Number Information
=====================================================
NPI Number | 1942164512
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DYLAN WILLIAM CORTESE BS, MSPAS, PA-C
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/09/2025
-----------------------------------------------------
Last Update Date | 12/10/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2770 LEWISVILLE CLEMMONS RD
-----------------------------------------------------
City | CLEMMONS
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27012-8716
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 336-766-0324
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2077 ROSSMORE RD
-----------------------------------------------------
City | CLEMMONS
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27012-7911
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 336-406-5643
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363A00000X
-----------------------------------------------------
Taxonomy Name | Physician Assistant
-----------------------------------------------------
License Number | 0010-15663
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------