Provider Demographics
NPI:1376516369
Name:NIEMEYER JR, CHARLES JOHN (PAC)
Entity Type:Individual
Prefix:MR
First Name:CHARLES
Middle Name:JOHN
Last Name:NIEMEYER JR
Suffix:
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2345 COURT DRIVE
Mailing Address - Street 2:
Mailing Address - City:GASTONIA
Mailing Address - State:NC
Mailing Address - Zip Code:28054
Mailing Address - Country:US
Mailing Address - Phone:704-865-0077
Mailing Address - Fax:704-867-6401
Practice Address - Street 1:2345 COURT DRIVE
Practice Address - Street 2:
Practice Address - City:GASTONIA
Practice Address - State:NC
Practice Address - Zip Code:28054
Practice Address - Country:US
Practice Address - Phone:704-865-0077
Practice Address - Fax:704-867-6401
Is Sole Proprietor?:No
Enumeration Date:2006-02-09
Last Update Date:2019-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC102452363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
S26718Medicare UPIN
NC2745370BMedicare ID - Type Unspecified