Healthcare Provider Details

I. General information

NPI: 1346921913
Provider Name (Legal Business Name): CAITLIN ONTIVEROS PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: CAITLIN TOMINEY

II. Dates (important events)

Enumeration Date: 07/27/2023
Last Update Date: 02/24/2026
Certification Date: 02/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7210 VILLAGE MEDICAL CIR STE 310
CLEMMONS NC
27012-8041
US

IV. Provider business mailing address

PO BOX 60447
CHARLOTTE NC
28260-0447
US

V. Phone/Fax

Practice location:
  • Phone: 336-277-4075
  • Fax: 336-277-4070
Mailing address:
  • Phone: 336-277-4075
  • Fax: 336-277-4070

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number0010-14694
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: