Healthcare Provider Details

I. General information

NPI: 1154242378
Provider Name (Legal Business Name): TATUM RENEE MCBRIDE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/23/2026
Last Update Date: 07/23/2026
Certification Date: 07/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2555 COURT DR STE 450
GASTONIA NC
28054-2191
US

IV. Provider business mailing address

2555 COURT DR STE 450
GASTONIA NC
28054-2191
US

V. Phone/Fax

Practice location:
  • Phone: 704-671-7652
  • Fax: 704-671-7656
Mailing address:
  • Phone: 704-671-7652
  • Fax: 704-671-7656

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number0010-16825
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: