Provider Demographics
NPI:1972969970
Name:DEWOLF, JEREMY (PA-C)
Entity Type:Individual
Prefix:
First Name:JEREMY
Middle Name:
Last Name:DEWOLF
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 1:645 AMALIA ST NE
Mailing Address - Street 2:
Mailing Address - City:CONCORD
Mailing Address - State:NC
Mailing Address - Zip Code:28025-2434
Mailing Address - Country:US
Mailing Address - Phone:704-295-3255
Mailing Address - Fax:704-295-7791
Practice Address - Street 1:645 AMALIA ST NE
Practice Address - Street 2:
Practice Address - City:CONCORD
Practice Address - State:NC
Practice Address - Zip Code:28025-2434
Practice Address - Country:US
Practice Address - Phone:704-295-3255
Practice Address - Fax:704-295-7791
Is Sole Proprietor?:No
Enumeration Date:2016-01-06
Last Update Date:2021-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
0010-06156363A00000X
NC0010-06156363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant