Provider Demographics
NPI:1356570188
Name:RICHARDSON, DAVID WAYLON (FNP-C)
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:WAYLON
Last Name:RICHARDSON
Suffix:
Gender:M
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2032 S 17TH ST
Mailing Address - Street 2:SUITE 101
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28401-6678
Mailing Address - Country:US
Mailing Address - Phone:910-763-3738
Mailing Address - Fax:910-763-0454
Practice Address - Street 1:2032 S 17TH ST
Practice Address - Street 2:SUITE 101
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28401-6678
Practice Address - Country:US
Practice Address - Phone:910-763-3738
Practice Address - Fax:910-763-0454
Is Sole Proprietor?:No
Enumeration Date:2009-07-14
Last Update Date:2013-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5004418363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7000566Medicaid
NC2594299AMedicare PIN