Provider Demographics
NPI:1326327610
Name:SEXTON, JEREMY WADE (PA)
Entity Type:Individual
Prefix:
First Name:JEREMY
Middle Name:WADE
Last Name:SEXTON
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4109 RIVER BIRCH DR
Mailing Address - Street 2:
Mailing Address - City:IRON STATION
Mailing Address - State:NC
Mailing Address - Zip Code:28080-8509
Mailing Address - Country:US
Mailing Address - Phone:704-999-3452
Mailing Address - Fax:
Practice Address - Street 1:1531 N ASPEN ST
Practice Address - Street 2:
Practice Address - City:LINCOLNTON
Practice Address - State:NC
Practice Address - Zip Code:28092-7268
Practice Address - Country:US
Practice Address - Phone:704-732-8736
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-08-04
Last Update Date:2014-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-03042363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical