Healthcare Provider Details

I. General information

NPI: 1922003508
Provider Name (Legal Business Name): CARA M DEPANFILIS PAC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/20/2005
Last Update Date: 07/09/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5900 LAKE WRIGHT DR
NORFOLK VA
23502-1871
US

IV. Provider business mailing address

5900 LAKE WRIGHT DR SUITE 300
NORFOLK VA
23502-1871
US

V. Phone/Fax

Practice location:
  • Phone: 757-466-8683
  • Fax: 757-466-8892
Mailing address:
  • Phone: 757-213-5700
  • Fax: 757-213-5701

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number0110001570
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: