Basic Information
| Provider Information | |||||||||
| NPI: | 1386606564 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BAILEY | ||||||||
| FirstName: | CORTIS | ||||||||
| MiddleName: | WARD | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | II | ||||||||
| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4402 SHIPYARD BLVD | ||||||||
| Address2: | |||||||||
| City: | WILMINGTON | ||||||||
| State: | NC | ||||||||
| PostalCode: | 284036161 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9104521400 | ||||||||
| FaxNumber: | 9103321072 | ||||||||
| Practice Location | |||||||||
| Address1: | 4402 SHIPYARD BLVD | ||||||||
| Address2: | |||||||||
| City: | WILMINGTON | ||||||||
| State: | NC | ||||||||
| PostalCode: | 284036161 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9104521400 | ||||||||
| FaxNumber: | 9103321072 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/04/2006 | ||||||||
| LastUpdateDate: | 09/23/2010 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 000104167 | NC | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | P00222783 | 01 | NC | RAILROAD MEDICARE | OTHER | 0936PA | 01 | SC | MEDICAID OF SC | OTHER |