Provider Demographics
NPI:1356386106
Name:WELBORN, REGGIE NEIL (PA-C)
Entity type:Individual
Prefix:
First Name:REGGIE
Middle Name:NEIL
Last Name:WELBORN
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:MEDICAL CENTER BLVD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27157-0001
Mailing Address - Country:US
Mailing Address - Phone:336-716-2255
Mailing Address - Fax:336-716-3202
Practice Address - Street 1:2025 FRONTIS PLAZA BLVD
Practice Address - Street 2:SUITE 200
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27103-5663
Practice Address - Country:US
Practice Address - Phone:336-768-6211
Practice Address - Fax:336-768-6869
Is Sole Proprietor?:No
Enumeration Date:2006-06-17
Last Update Date:2023-06-07
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NC0010-00133363AM0700X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCQ50104Medicare UPIN
NC2763989Medicare ID - Type Unspecified