Provider Demographics
NPI:1205262029
Name:SUROVCHAK, DAVID JOHN (PA-C)
Entity type:Individual
Prefix:MR
First Name:DAVID
Middle Name:JOHN
Last Name:SUROVCHAK
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 1:303 GREEN ST E
Mailing Address - Street 2:
Mailing Address - City:WILSON
Mailing Address - State:NC
Mailing Address - Zip Code:27893-4105
Mailing Address - Country:US
Mailing Address - Phone:252-293-0013
Mailing Address - Fax:252-243-2576
Practice Address - Street 1:303 GREEN ST E
Practice Address - Street 2:
Practice Address - City:WILSON
Practice Address - State:NC
Practice Address - Zip Code:27893-4105
Practice Address - Country:US
Practice Address - Phone:252-243-9800
Practice Address - Fax:252-243-9888
Is Sole Proprietor?:No
Enumeration Date:2013-09-25
Last Update Date:2024-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-04495363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
12642518OtherCAQH