Provider Demographics
NPI:1760471221
Name:WIGHT, IRVING DAVID (PA-C)
Entity Type:Individual
Prefix:MR
First Name:IRVING
Middle Name:DAVID
Last Name:WIGHT
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:6035 FAIRVIEW RD
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28210-3256
Mailing Address - Country:US
Mailing Address - Phone:704-295-3000
Mailing Address - Fax:704-295-3468
Practice Address - Street 1:1401 MATTHEWS TOWNSHIP PKWY
Practice Address - Street 2:SUITE 101
Practice Address - City:MATTHEWS
Practice Address - State:NC
Practice Address - Zip Code:28105-5402
Practice Address - Country:US
Practice Address - Phone:704-295-3550
Practice Address - Fax:704-295-3556
Is Sole Proprietor?:No
Enumeration Date:2005-10-18
Last Update Date:2009-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC100635363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC98462OtherMEDCOST
970023482OtherMEDICARE RR
970023482OtherMEDICARE RR
NCS94670Medicare UPIN