Basic Information
| Provider Information | |||||||||
| NPI: | 1730178880 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CAPO | ||||||||
| FirstName: | RICHARD | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4601 PARK RD | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282093239 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7043232000 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1422 OLD WEISGARBER RD | ||||||||
| Address2: | |||||||||
| City: | KNOXVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 379091293 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8655584400 | ||||||||
| FaxNumber: | 8655584421 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/20/2005 | ||||||||
| LastUpdateDate: | 08/15/2019 | ||||||||
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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 | 0010-04639 | NC | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 0010-04639 | 01 | NC | NC MEDICAL LICENSE | OTHER |