Provider Demographics
NPI:1265517122
Name:LANGSTON, JONATHAN LAWRENCE (PAC)
Entity type:Individual
Prefix:
First Name:JONATHAN
Middle Name:LAWRENCE
Last Name:LANGSTON
Suffix:
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:SHALLOTTE MEDICAL CENTER INC
Mailing Address - Street 2:PO BOX 2561
Mailing Address - City:SHALLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28459
Mailing Address - Country:US
Mailing Address - Phone:910-754-8731
Mailing Address - Fax:910-754-3153
Practice Address - Street 1:SHALLOTTE MEDICAL CENTER INC
Practice Address - Street 2:341A WHITEVILLE RD
Practice Address - City:SHALLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28470
Practice Address - Country:US
Practice Address - Phone:910-754-8731
Practice Address - Fax:910-754-3153
Is Sole Proprietor?:No
Enumeration Date:2006-10-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC100214207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
Q06413Medicare UPIN
NC2759447Medicare ID - Type Unspecified