MEDICARE: MRS. CHERRYL LAI KLITCH 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	363AM0700X	Medical Physician Assistant	PA9105052	FL
2	363AM0700X	Medical Physician Assistant	0010-06921	NC
3	363A00000X	Physician Assistant	0010-06921	NC

General Provider Information

NPI Number	:	1033445879
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. CHERRYL LAI KLITCH PA-C

Provider Business Mailing Address
First Line	:	PO BOX 60447
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28260-0447
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	9600 E INDEPENDENCE BLVD STE B
Second Line	:
City	:	MATTHEWS
State	:	NC
Zip	:	28105-4628
Country	:	US
Telephone Number	:	704-815-5624
Fax Number	:	704-815-5621

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

Provider Enumeration Date	:	10/29/2009
Last Update Date	:	11/01/2021

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