Healthcare Provider Details

I. General information

NPI: 1336793330
Provider Name (Legal Business Name): ANSLEY SWANN PA-C, ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/29/2019
Last Update Date: 03/23/2026
Certification Date: 03/23/2026
Deactivation Date: 02/25/2026
Reactivation Date: 03/23/2026

III. Provider practice location address

11221 GALLERIA AVE STE 101
RALEIGH NC
27614-8137
US

IV. Provider business mailing address

1243 PATRICK CIR APT B
CARY NC
27511-4929
US

V. Phone/Fax

Practice location:
  • Phone: 919-562-9410
  • Fax:
Mailing address:
  • Phone: 704-989-1856
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number0010-16224
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberLAT-5840
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: