Provider Demographics
NPI:1730141938
Name:SANDIDGE, DARRYL (PA)
Entity Type:Individual
Prefix:
First Name:DARRYL
Middle Name:
Last Name:SANDIDGE
Suffix:
Gender:M
Credentials:PA
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 602195
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-2195
Mailing Address - Country:US
Mailing Address - Phone:919-350-8991
Mailing Address - Fax:919-350-7687
Practice Address - Street 1:1260 N ARENDELL AVE
Practice Address - Street 2:
Practice Address - City:ZEBULON
Practice Address - State:NC
Practice Address - Zip Code:27597-8730
Practice Address - Country:US
Practice Address - Phone:919-235-1965
Practice Address - Fax:919-235-1326
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-04
Last Update Date:2022-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-06204261QU0200X, 363A00000X
FLPA9102240363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC0010-06204OtherNC MEDICAL BOARD
FLP32016Medicare UPIN