Provider Demographics
NPI:1497200117
Name:WOMBLE, WALKER SCHOTT (PA-C)
Entity Type:Individual
Prefix:
First Name:WALKER
Middle Name:SCHOTT
Last Name:WOMBLE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:MAGDELINE
Other - Middle Name:WALKER
Other - Last Name:SCHOTT
Other - Suffix:
Other - Last Name Type:Former Name
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:
Mailing Address - Fax:
Practice Address - Street 1:5010 PETERS CREEK PKWY
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27127-7276
Practice Address - Country:US
Practice Address - Phone:336-788-4664
Practice Address - Fax:336-788-0753
Is Sole Proprietor?:No
Enumeration Date:2016-08-23
Last Update Date:2023-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-06665363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
1134645OtherNCCPA