Healthcare Provider Details

I. General information

NPI: 1962160549
Provider Name (Legal Business Name): MICHELLE VICTORIA- DOMINIQUE HARVEY PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/01/2021
Last Update Date: 06/19/2023
Certification Date: 06/19/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

203 SALISBURY ST
WADESBORO NC
28170-2155
US

IV. Provider business mailing address

203 SALISBURY ST
WADESBORO NC
28170-2155
US

V. Phone/Fax

Practice location:
  • Phone: 704-694-6700
  • Fax: 704-695-1227
Mailing address:
  • Phone: 704-694-6700
  • Fax: 704-695-1227

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number0010-11821
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: