Provider Demographics
NPI:1639263775
Name:WANGERIN LILE, DAVID DONALD (PA-C)
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:DONALD
Last Name:WANGERIN LILE
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 1:1272 EAST STREET
Mailing Address - Street 2:
Mailing Address - City:WAYNESVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28786-3437
Mailing Address - Country:US
Mailing Address - Phone:828-456-3511
Mailing Address - Fax:828-456-3583
Practice Address - Street 1:1272 EAST STREET
Practice Address - Street 2:
Practice Address - City:WAYNESVILLE
Practice Address - State:NC
Practice Address - Zip Code:28786
Practice Address - Country:US
Practice Address - Phone:828-456-3511
Practice Address - Fax:828-456-3583
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2019-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC102410207Q00000X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC10276OtherBCBS
NC10276OtherBCBS
P31790Medicare UPIN
NC2748111AMedicare PIN