Healthcare Provider Details

I. General information

NPI: 1487633137
Provider Name (Legal Business Name): MELISSA A VANAUSDOLL PAC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/11/2006
Last Update Date: 06/21/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7110 LAWYERS RD
MINT HILL NC
28227-3906
US

IV. Provider business mailing address

PO BOX 602362
CHARLOTTE NC
28260-2362
US

V. Phone/Fax

Practice location:
  • Phone: 704-537-0020
  • Fax: 704-537-2144
Mailing address:
  • Phone: 704-537-0020
  • Fax: 704-537-2144

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number103382
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number103382
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: