Healthcare Provider Details

I. General information

NPI: 1275293839
Provider Name (Legal Business Name): MAEPEARL ST GEORGE PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/23/2021
Last Update Date: 07/06/2026
Certification Date: 07/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10685 CARNEGIE AVE # X20
CLEVELAND OH
44106-3018
US

IV. Provider business mailing address

10685 CARNEGIE AVE # X20
CLEVELAND OH
44106-3018
US

V. Phone/Fax

Practice location:
  • Phone: 216-444-6568
  • Fax:
Mailing address:
  • Phone: 216-444-6568
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number50.008246RX
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: