Healthcare Provider Details

I. General information

NPI: 1962405688
Provider Name (Legal Business Name): DEBORAH ANNE HAUBERT PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: DEBORAH ANNE MOTYL PA-C

II. Dates (important events)

Enumeration Date: 05/27/2005
Last Update Date: 10/29/2020
Certification Date: 10/29/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1995 BETHABARA RD
WINSTON-SALEM NC
27106-3375
US

IV. Provider business mailing address

PO BOX 751803
CHARLOTTE NC
28275-1803
US

V. Phone/Fax

Practice location:
  • Phone: 336-759-7596
  • Fax: 336-759-3652
Mailing address:
  • Phone: 336-759-7596
  • Fax: 336-759-3652

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number102304
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number102304
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: