MEDICARE: JEFFREY WAYNE AUTRY FNP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363L00000X	Nurse Practitioner	105149	NC

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	2344540	OTHER	NC	MEDICARE GROUP NO
2	2806457A	OTHER	NC	MEDICARE INDIV PROVIDER

General Provider Information

NPI Number	:	1063474559
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JEFFREY WAYNE AUTRY FNP

Provider Business Mailing Address
First Line	:	1004 BEAMON ST.
Second Line	:
City	:	CLINTON
State	:	NC
Zip	:	28328-0227
Country	:	US
Telephone Number	:	910-592-9113
Fax Number	:	910-590-0050

Provider Business Practice Location Address
First Line	:	1004 BEAMON ST.
Second Line	:
City	:	CLINTON
State	:	NC
Zip	:	28328-0227
Country	:	US
Telephone Number	:	910-592-9113
Fax Number	:	910-590-0050

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/03/2006
Last Update Date	:	11/21/2007

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