MEDICARE: SYDNEY THAMES DIAKALELA PA-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant	0010-13213	NC

General Provider Information

NPI Number	:	1003500091
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SYDNEY THAMES DIAKALELA PA-C

Provider Business Mailing Address
First Line	:	3570 TORINGDON WAY APT 1061
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28277-4906
Country	:	US
Telephone Number	:	704-806-4717
Fax Number	:

Provider Business Practice Location Address
First Line	:	3570 TORINGDON WAY APT 1061
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28277-4906
Country	:	US
Telephone Number	:	704-806-4717
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/05/2023
Last Update Date	:	06/05/2023

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