Healthcare Provider Details

I. General information

NPI: 1235869272
Provider Name (Legal Business Name): PETTER MAWAD ROPHAEL PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/13/2022
Last Update Date: 12/11/2025
Certification Date: 12/11/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 BLYTHE BLVD
CHARLOTTE NC
28203-5812
US

IV. Provider business mailing address

PO BOX 19305
CHARLOTTE NC
28219-9305
US

V. Phone/Fax

Practice location:
  • Phone: 704-355-0720
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number0010-11733
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number0010-11733
License Number StateNC
# 3
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number4882
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: