MEDICARE: MR. VICTOR G WITHERSPOON II PA-S

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	390200000X	Student in an Organized Health Care Education/Training Program		NC

General Provider Information

NPI Number	:	1467386029
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. VICTOR G WITHERSPOON II PA-S

Provider Business Mailing Address
First Line	:	774 FRANKLIN TREE DR NW
Second Line	:
City	:	CONCORD
State	:	NC
Zip	:	28027-8314
Country	:	US
Telephone Number	:	704-497-1047
Fax Number	:

Provider Business Practice Location Address
First Line	:	1021 MOREHEAD MEDICAL DR
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28204-2839
Country	:	US
Telephone Number	:	980-442-2000
Fax Number	:

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

Provider Enumeration Date	:	06/10/2026
Last Update Date	:	06/10/2026

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