Healthcare Provider Details

I. General information

NPI: 1932194503
Provider Name (Legal Business Name): MICHELE MARIA JARBEAU PA
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 09/20/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

991 W HUDSON BLVD
GASTONIA NC
28052-6430
US

IV. Provider business mailing address

991 W HUDSON BLVD
GASTONIA NC
28052-6430
US

V. Phone/Fax

Practice location:
  • Phone: 704-853-5079
  • Fax: 704-853-5269
Mailing address:
  • Phone: 704-853-5079
  • Fax: 704-853-5269

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number102063
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: