Provider Demographics
NPI:1366442733
Name:WERNER, HARRY
Entity Type:Individual
Prefix:
First Name:HARRY
Middle Name:
Last Name:WERNER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 60447
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-0447
Mailing Address - Country:US
Mailing Address - Phone:704-384-1140
Mailing Address - Fax:704-384-1141
Practice Address - Street 1:1995 WELLNESS BLVD
Practice Address - Street 2:STE 110, BLDG B
Practice Address - City:MONROE
Practice Address - State:NC
Practice Address - Zip Code:28110-7769
Practice Address - Country:US
Practice Address - Phone:704-384-1140
Practice Address - Fax:704-384-1141
Is Sole Proprietor?:No
Enumeration Date:2005-07-28
Last Update Date:2020-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY174873207Q00000X, 207QS0010X
NC2012-02352207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY1117519Medicaid
NY56475PMedicare PIN
NY1117519Medicaid