Provider Demographics
NPI:1639251408
Name:WOGLOM, PETER BECK (PA-C)
Entity type:Individual
Prefix:MR
First Name:PETER
Middle Name:BECK
Last Name:WOGLOM
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 1:1305 MEADOW RD
Mailing Address - Street 2:
Mailing Address - City:COLERAIN
Mailing Address - State:NC
Mailing Address - Zip Code:27924-9014
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:218 COOPER HILL RD
Practice Address - Street 2:
Practice Address - City:WINDSOR
Practice Address - State:NC
Practice Address - Zip Code:27983-8501
Practice Address - Country:US
Practice Address - Phone:252-794-8600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC101652363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCS44335Medicare UPIN