Healthcare Provider Details

I. General information

NPI: 1164003570
Provider Name (Legal Business Name): JOHNATHAN DONALD DEBETTA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/16/2021
Last Update Date: 12/07/2021
Certification Date: 12/07/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4350 US 421 S
LILLINGTON NC
27546-6760
US

IV. Provider business mailing address

10118 KNOTTY PINE LN
RALEIGH NC
27617-8218
US

V. Phone/Fax

Practice location:
  • Phone: 910-893-1210
  • Fax:
Mailing address:
  • Phone: 631-678-8049
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number0010-11534
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: