Healthcare Provider Details

I. General information

NPI: 1992762538
Provider Name (Legal Business Name): MARY DEAKLE PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/27/2006
Last Update Date: 10/28/2020
Certification Date: 09/06/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6301 STADIUM DR
CLEMMONS NC
27012-8766
US

IV. Provider business mailing address

PO BOX 751803
CHARLOTTE NC
28275-1803
US

V. Phone/Fax

Practice location:
  • Phone: 336-766-6473
  • Fax: 336-766-8909
Mailing address:
  • Phone: 336-766-6473
  • Fax: 336-766-8909

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number100874
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number100874
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: