Healthcare Provider Details

I. General information

NPI: 1972577633
Provider Name (Legal Business Name): MICHELLE ANN ROMAN PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MICHELLE ANN DOMASKY PA-C

II. Dates (important events)

Enumeration Date: 02/17/2006
Last Update Date: 11/22/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2716 ASHTON DR
WILMINGTON NC
28412-2489
US

IV. Provider business mailing address

2716 ASHTON DR
WILMINGTON NC
28412-2489
US

V. Phone/Fax

Practice location:
  • Phone: 910-332-3800
  • Fax:
Mailing address:
  • Phone: 910-332-3800
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number103509
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number103509
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: