Healthcare Provider Details

I. General information

NPI: 1629852546
Provider Name (Legal Business Name): ELLEN MARIE MUIR PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/22/2023
Last Update Date: 05/31/2024
Certification Date: 05/31/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2400 W FRIENDLY AVE
GREENSBORO NC
27403-1109
US

IV. Provider business mailing address

200 QUEENS RD STE 400
CHARLOTTE NC
28204-3264
US

V. Phone/Fax

Practice location:
  • Phone: 336-832-1100
  • Fax:
Mailing address:
  • Phone: 980-890-6063
  • Fax: 704-333-3397

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number0010-13659
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: