Basic Information
| Provider Information | |||||||||
| NPI: | 1730141938 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SANDIDGE | ||||||||
| FirstName: | DARRYL | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 602195 | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282602195 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9193508991 | ||||||||
| FaxNumber: | 9193507687 | ||||||||
| Practice Location | |||||||||
| Address1: | 1260 N ARENDELL AVE | ||||||||
| Address2: | |||||||||
| City: | ZEBULON | ||||||||
| State: | NC | ||||||||
| PostalCode: | 275978730 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9192351965 | ||||||||
| FaxNumber: | 9192351326 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/04/2006 | ||||||||
| LastUpdateDate: | 10/27/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 10/25/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QU0200X | 0010-06204 | NC | N | Ambulatory Health Care Facilities | Clinic/Center | Urgent Care | 363A00000X | PA9102240 | FL | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363A00000X | 0010-06204 | NC | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 0010-06204 | 01 | NC | NC MEDICAL BOARD | OTHER |