Healthcare Provider Details

I. General information

NPI: 1881774883
Provider Name (Legal Business Name): KAREN MEISENBACH BOOTH PAC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KAREN RENEE MEISENBACCH

II. Dates (important events)

Enumeration Date: 10/16/2006
Last Update Date: 05/06/2021
Certification Date: 05/06/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2605 BLUE RIDGE RD SUITE 300
RALEIGH NC
27607
US

IV. Provider business mailing address

2000 PERIMETER PARK DR STE 200
MORRISVILLE NC
27560-8442
US

V. Phone/Fax

Practice location:
  • Phone: 919-787-3448
  • Fax: 919-232-0006
Mailing address:
  • Phone: 984-215-4110
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number001000196
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: