1861505828 NPI number — MRS. CAROLINE BROOKE JUSTUS PA-C

Table of content: MRS. CAROLINE BROOKE JUSTUS PA-C (NPI 1861505828)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1861505828 NPI number — MRS. CAROLINE BROOKE JUSTUS PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
JUSTUS
Provider First Name:
CAROLINE
Provider Middle Name:
BROOKE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
PA-C
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
FLETCHER
Provider Other First Name:
CAROLINE
Provider Other Middle Name:
BROOKE
Provider Other Name Prefix Text:
MS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
PA-C
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1861505828
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/24/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 601643
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHARLOTTE
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28260-1643
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
704-302-8200
Provider Business Mailing Address Fax Number:
704-302-8201

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3030 RANDOLPH RD
Provider Second Line Business Practice Location Address:
SUITE 200, MMG MUSEUM
Provider Business Practice Location Address City Name:
CHARLOTTE
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28211-1368
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
704-302-8200
Provider Business Practice Location Address Fax Number:
704-302-8201
Provider Enumeration Date:
08/16/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363A00000X , with the licence number:  103732 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 8101156 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0189PA , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1861505828 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".




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