Provider Demographics
NPI:1952490013
Name:PAVAO, JAMES JOSEPH (PA-C)
Entity Type:Individual
Prefix:MR
First Name:JAMES
Middle Name:JOSEPH
Last Name:PAVAO
Suffix:
Gender:M
Credentials:PA-C
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 751649
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28275-1649
Mailing Address - Country:US
Mailing Address - Phone:843-789-1620
Mailing Address - Fax:843-724-2440
Practice Address - Street 1:2145 HENRY TECKLENBURG DR
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29414-5893
Practice Address - Country:US
Practice Address - Phone:843-723-8823
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-12
Last Update Date:2015-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1582363AS0400X
SC1325363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP5006OtherMEDICAID GROUP #
SCGP5005OtherMEDICAID GROUP #
SCGP5072OtherMEDICAID GROUP #
SC5551OtherMEDICARE GROUP #
SC0733PAMedicaid
SCGP5004OtherMEDICAID GROUP #
SCP00648630OtherRAILROAD MEDICARE ID
SCGP5007OtherMEDICAID GROUP #
SCGP5005OtherMEDICAID GROUP #
SC0733PAMedicaid