Healthcare Provider Details

I. General information

NPI: 1003053935
Provider Name (Legal Business Name): PHILIP MAXIMILIAN DAYVAULT PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/14/2009
Last Update Date: 11/26/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1035 LINCOLNTON RD
SALISBURY NC
28144-6277
US

IV. Provider business mailing address

1718 E 4TH ST SUITE 902
CHARLOTTE NC
28204-3261
US

V. Phone/Fax

Practice location:
  • Phone: 704-638-9990
  • Fax: 704-639-0785
Mailing address:
  • Phone: 704-638-9990
  • Fax: 704-639-0785

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number0010-01670
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: