Provider Demographics
NPI:1154737898
Name:SELLERS, WILLIAM DUSTIN (PA-C)
Entity type:Individual
Prefix:MR
First Name:WILLIAM
Middle Name:DUSTIN
Last Name:SELLERS
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 1:2808 MAPLEWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27103-4138
Mailing Address - Country:US
Mailing Address - Phone:336-765-9000
Mailing Address - Fax:
Practice Address - Street 1:2808 MAPLEWOOD AVE
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27103-4138
Practice Address - Country:US
Practice Address - Phone:336-765-9000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-07-02
Last Update Date:2015-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-05069363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1154737898Medicaid
NCNCK802AMedicare PIN
SC1979PAMedicaid