Healthcare Provider Details

I. General information

NPI: 1336771278
Provider Name (Legal Business Name): GRACE E PAK MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/09/2020
Last Update Date: 07/15/2026
Certification Date: 07/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 BLYTHE BLVD
CHARLOTTE NC
28203-5871
US

IV. Provider business mailing address

1000 BLYTHE BLVD
CHARLOTTE NC
28203-5871
US

V. Phone/Fax

Practice location:
  • Phone: 704-355-2000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number2026-02443
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number2026-02443
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: