MEDICARE: JADA MARIE DILLNER PA-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	390200000X	Student in an Organized Health Care Education/Training Program
2	363A00000X	Physician Assistant
3	363A00000X	Physician Assistant	0010-12516	NC

General Provider Information

NPI Number	:	1225789662
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JADA MARIE DILLNER PA-C

Provider Business Mailing Address
First Line	:	11640 NORTHPARK DR STE 200
Second Line	:
City	:	WAKE FOREST
State	:	NC
Zip	:	27587-5741
Country	:	US
Telephone Number	:	919-436-4124
Fax Number	:

Provider Business Practice Location Address
First Line	:	11640 NORTHPARK DR STE 200
Second Line	:
City	:	WAKE FOREST
State	:	NC
Zip	:	27587-5741
Country	:	US
Telephone Number	:	919-436-4124
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/18/2022
Last Update Date	:	06/24/2024

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