Healthcare Provider Details

I. General information

NPI: 1205268448
Provider Name (Legal Business Name): JENNIFER E MIXTER P.A.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/30/2013
Last Update Date: 12/13/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

501 S SHARON AMITY RD STE 300
CHARLOTTE NC
28211-0035
US

IV. Provider business mailing address

501 S SHARON AMITY RD STE 300
CHARLOTTE NC
28211-0035
US

V. Phone/Fax

Practice location:
  • Phone: 704-377-2424
  • Fax: 704-377-2687
Mailing address:
  • Phone: 704-377-2424
  • Fax: 704-377-2687

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberC0005069
License Number StateMD
# 2
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number0010-05528
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: