Provider Demographics
NPI:1407271026
Name:SPOON, JEFFREY JAMES (PA-C)
Entity Type:Individual
Prefix:MR
First Name:JEFFREY
Middle Name:JAMES
Last Name:SPOON
Suffix:
Gender:M
Credentials:PA-C
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:704-384-9437
Mailing Address - Fax:704-384-9440
Practice Address - Street 1:1918 RANDOLPH RD STE 400
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28207-1196
Practice Address - Country:US
Practice Address - Phone:704-384-9437
Practice Address - Fax:704-384-9440
Is Sole Proprietor?:No
Enumeration Date:2014-02-19
Last Update Date:2023-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-05848363A00000X
TXPA08818363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1407271026Medicaid
SC2394PAMedicaid
SC2394PAMedicaid
NCNCQ138CMedicare PIN
NCNCQ138DMedicare PIN
NC1407271026Medicaid