Provider Demographics
NPI:1205177714
Name:WHARTON, LISA VIRGINIA (PA-C)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:VIRGINIA
Last Name:WHARTON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:VIRGINIA
Other - Last Name:KOTTKE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:104 PERQUIMANS DR
Mailing Address - Street 2:
Mailing Address - City:CHOCOWINITY
Mailing Address - State:NC
Mailing Address - Zip Code:27817-8886
Mailing Address - Country:US
Mailing Address - Phone:336-251-5646
Mailing Address - Fax:
Practice Address - Street 1:1412 CAROLINA AVE
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:NC
Practice Address - Zip Code:27889-3314
Practice Address - Country:US
Practice Address - Phone:252-623-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-03-07
Last Update Date:2014-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-04063363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical