Healthcare Provider Details

I. General information

NPI: 1588615538
Provider Name (Legal Business Name): MICHAEL B DURBIN P.A.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/15/2006
Last Update Date: 08/13/2021
Certification Date: 08/13/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17078 NAT BYNUM LN UNIT 3
CORNELIUS NC
28031-0507
US

IV. Provider business mailing address

PO BOX 60447
CHARLOTTE NC
28260-0447
US

V. Phone/Fax

Practice location:
  • Phone: 704-324-3975
  • Fax: 704-324-3974
Mailing address:
  • Phone: 704-384-1775
  • Fax: 704-384-1776

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number104046
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number104046
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: