MEDICARE: SAMUEL H WEATHERFORD 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	0010-05179	NC
2	363AS0400X	Surgical Physician Assistant	656	SC
3	363AM0700X	Medical Physician Assistant	0010-05179	NC

General Provider Information

NPI Number	:	1508075896
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SAMUEL H WEATHERFORD PA-C

Provider Business Mailing Address
First Line	:	112 MEDICAL VILLAGE DR STE F
Second Line	:
City	:	WALLACE
State	:	NC
Zip	:	28466-1665
Country	:	US
Telephone Number	:	910-285-0940
Fax Number	:	910-285-1825

Provider Business Practice Location Address
First Line	:	112 MEDICAL VILLAGE DR STE F
Second Line	:
City	:	WALLACE
State	:	NC
Zip	:	28466-1665
Country	:	US
Telephone Number	:	910-285-0940
Fax Number	:	910-285-1825

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

Provider Enumeration Date	:	05/22/2007
Last Update Date	:	07/26/2024

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