Provider Demographics
NPI:1801824784
Name:WAYNE, RICHARD LEE (PA)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:LEE
Last Name:WAYNE
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 602373
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-2373
Mailing Address - Country:US
Mailing Address - Phone:828-526-1280
Mailing Address - Fax:828-526-1285
Practice Address - Street 1:57 WHITE OWL LN
Practice Address - Street 2:
Practice Address - City:CASHIERS
Practice Address - State:NC
Practice Address - Zip Code:28717-4514
Practice Address - Country:US
Practice Address - Phone:828-743-2491
Practice Address - Fax:828-743-3060
Is Sole Proprietor?:No
Enumeration Date:2006-06-29
Last Update Date:2016-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC102994363AM0700X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCNC2041A194OtherMEDICARE PTAN
S50248Medicare UPIN
NCNC2041A194Medicare PIN