MEDICARE: MR. JOHN C. WADSWORTH 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	363A00000X	Physician Assistant	MA002111L	PA
2	363A00000X	Physician Assistant	0010-06043	NC

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
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1316998347
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. JOHN C. WADSWORTH PA-C

Provider Business Mailing Address
First Line	:	PO BOX 602484
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28260-2484
Country	:	US
Telephone Number	:	910-259-0400
Fax Number	:	910-259-0400

Provider Business Practice Location Address
First Line	:	7910 US HIGHWAY 117 S
Second Line	:	SUITE 120
City	:	ROCKY POINT
State	:	NC
Zip	:	28457-7409
Country	:	US
Telephone Number	:	910-259-0400
Fax Number	:	910-675-3030

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

Provider Enumeration Date	:	05/15/2006
Last Update Date	:	11/23/2016

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