MEDICARE: ALICIA BULLOUGH 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

General Provider Information

NPI Number	:	1215894217
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ALICIA BULLOUGH PA-C

Provider Business Mailing Address
First Line	:	3627 BEATTIES FORD RD
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28216-3249
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	3627 BEATTIES FORD RD
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28216-3249
Country	:	US
Telephone Number	:	704-335-0806
Fax Number	:

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

Provider Enumeration Date	:	01/09/2026
Last Update Date	:	01/15/2026

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