Provider Demographics
NPI:1467074666
Name:WOODARD, JEFFREY SAMUEL (PHYSICIAN ASSISTANT)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:SAMUEL
Last Name:WOODARD
Suffix:
Gender:M
Credentials:PHYSICIAN ASSISTANT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:901 HARVARD PL
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28207-1839
Mailing Address - Country:US
Mailing Address - Phone:980-329-2051
Mailing Address - Fax:
Practice Address - Street 1:10420 PARK RD STE 300
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28210-8502
Practice Address - Country:US
Practice Address - Phone:980-237-4766
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-11
Last Update Date:2021-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-10139363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant