=====================================================
General NPI Number Information
=====================================================
NPI Number | 1508084849
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SHANI FLEMING PA-C
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/23/2007
-----------------------------------------------------
Last Update Date | 01/31/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4001 TUCKASEEGEE RD
-----------------------------------------------------
City | CHARLOTTE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28208-2831
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 704-941-6000
-----------------------------------------------------
Fax | 704-586-9556
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4001 TUCKASEEGEE RD
-----------------------------------------------------
City | CHARLOTTE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28208-2831
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 704-941-6000
-----------------------------------------------------
Fax | 704-586-9556
-----------------------------------------------------
=====================================================
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 | C02991
-----------------------------------------------------
License Number State | MD
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363A00000X
-----------------------------------------------------
Taxonomy Name | Physician Assistant
-----------------------------------------------------
License Number | 0010-08021
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------