Provider Demographics
NPI:1710975438
Name:PATTERSON, JIMMY
Entity Type:Individual
Prefix:
First Name:JIMMY
Middle Name:
Last Name:PATTERSON
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 1:835 ALBEMARLE RD
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:NC
Mailing Address - Zip Code:27371-8682
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:210 E MAIN ST
Practice Address - Street 2:
Practice Address - City:CANDOR
Practice Address - State:NC
Practice Address - Zip Code:27229-8088
Practice Address - Country:US
Practice Address - Phone:910-974-7555
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-10-06
Last Update Date:2019-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC103094363A00000X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8101524Medicaid
NC1710975438Medicaid
NCNC4682BMedicare PIN
NC8101524Medicaid