Healthcare Provider Details

I. General information

NPI: 1588634372
Provider Name (Legal Business Name): CHARLENE MCCLURE MORRIS PAC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/24/2006
Last Update Date: 05/09/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

606 MAIN STREET
BAYBORO NC
28515
US

IV. Provider business mailing address

606 MAIN STREET
BAYBORO NC
28515
US

V. Phone/Fax

Practice location:
  • Phone: 252-745-3191
  • Fax: 252-745-7385
Mailing address:
  • Phone: 252-745-3191
  • Fax: 252-745-7385

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number102020
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number102020
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: