Healthcare Provider Details

I. General information

NPI: 1053208124
Provider Name (Legal Business Name): GRACE DELIA SABINE PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/21/2025
Last Update Date: 01/07/2026
Certification Date: 01/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

620 DR CALVIN JONES HWY
WAKE FOREST NC
27587-3107
US

IV. Provider business mailing address

1604 RADCLIFFE CT
NEWTOWN SQUARE PA
19073-1050
US

V. Phone/Fax

Practice location:
  • Phone: 919-761-5678
  • Fax:
Mailing address:
  • Phone: 732-861-7737
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number0010-15665
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: