Provider Demographics
NPI:1932191145
Name:DILLARD, WILBERT C (PAC)
Entity Type:Individual
Prefix:
First Name:WILBERT
Middle Name:C
Last Name:DILLARD
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:PO BOX 344
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27102-0344
Mailing Address - Country:US
Mailing Address - Phone:336-716-2255
Mailing Address - Fax:
Practice Address - Street 1:WINSTON EAST PEDIATRICS
Practice Address - Street 2:2295 EAST 14TH STREET SUITE 100
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27105
Practice Address - Country:US
Practice Address - Phone:336-716-2255
Practice Address - Fax:336-725-2173
Is Sole Proprietor?:No
Enumeration Date:2005-08-16
Last Update Date:2011-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC101969363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC2759360AMedicare PIN