MEDICARE: MR. JESSE WILLIAM PRICE III PA-C

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	363AM0700X	Medical Physician Assistant	1738	SC

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1093091761
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. JESSE WILLIAM PRICE III PA-C

Provider Business Mailing Address
First Line	:	PO BOX 751649
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28275-1649
Country	:	US
Telephone Number	:	843-789-1620
Fax Number	:	843-724-2440

Provider Business Practice Location Address
First Line	:	180 WINGO WAY
Second Line	:	SUITE 306
City	:	MT PLEASANT
State	:	SC
Zip	:	29464-1812
Country	:	US
Telephone Number	:	843-884-1777
Fax Number	:	843-884-0710

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

Provider Enumeration Date	:	10/26/2011
Last Update Date	:	01/05/2022

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