Healthcare Provider Details

I. General information

NPI: 1902875206
Provider Name (Legal Business Name): NORMAN HENTHORN PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/17/2006
Last Update Date: 04/29/2021
Certification Date: 04/29/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

107 W HARGETT ST
RALEIGH NC
27601-1700
US

IV. Provider business mailing address

5333 CULTIVATION LN
RALEIGH NC
27616-4331
US

V. Phone/Fax

Practice location:
  • Phone: 919-550-0821
  • Fax:
Mailing address:
  • Phone: 207-975-1658
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number0010-08283
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: