Provider Demographics
NPI:1922054261
Name:WARD, TOD RANDALL (PA-C)
Entity Type:Individual
Prefix:
First Name:TOD
Middle Name:RANDALL
Last Name:WARD
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:TOD
Other - Middle Name:RANDALL
Other - Last Name:WARD
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PA-C
Mailing Address - Street 1:PO BOX 601843
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-1843
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1977 COTTON GROVE RD
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:NC
Practice Address - Zip Code:27292-5721
Practice Address - Country:US
Practice Address - Phone:336-443-6041
Practice Address - Fax:336-443-6042
Is Sole Proprietor?:No
Enumeration Date:2006-05-26
Last Update Date:2022-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC103942363AM0700X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
199311OtherMEDCOST
7753971OtherAETNA
2760780Medicare PIN
199311OtherMEDCOST
Q20025Medicare UPIN
7753971OtherAETNA