=====================================================
General NPI Number Information
=====================================================
NPI Number | 1346967734
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MARCELA PROVENZANO PA-C
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/26/2022
-----------------------------------------------------
Last Update Date | 08/15/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 10207 CERNY ST STE 102
-----------------------------------------------------
City | RALEIGH
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27617-4880
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 919-613-1807
-----------------------------------------------------
Fax | 919-544-6907
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 10207 CERNY ST STE 102
-----------------------------------------------------
City | RALEIGH
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27617-4880
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 919-613-1807
-----------------------------------------------------
Fax | 919-544-6907
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363A00000X
-----------------------------------------------------
Taxonomy Name | Physician Assistant
-----------------------------------------------------
License Number | 0010-12733
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------