MEDICARE: JOHN SARDELLA 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	101496	NC

General Provider Information

NPI Number	:	1356433171
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JOHN SARDELLA PA-C

Provider Business Mailing Address
First Line	:	10250 TIMBER RIDGE CT SE
Second Line	:
City	:	LELAND
State	:	NC
Zip	:	28451-8536
Country	:	US
Telephone Number	:	910-520-1514
Fax Number	:

Provider Business Practice Location Address
First Line	:	4654 LONG BEACH RD SE
Second Line	:
City	:	SOUTHPORT
State	:	NC
Zip	:	28461-8799
Country	:	US
Telephone Number	:	910-457-9564
Fax Number	:

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

Provider Enumeration Date	:	09/29/2006
Last Update Date	:	12/03/2007

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