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NPI Code Detail

MEDICARE: MR. GABRIEL LAMONT OLLISON PA-C

MEDICARE: MR. GABRIEL LAMONT OLLISON 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
1363A00000XPhysician Assistant0010-10900NC

General Provider Information

NPI Number : 1609464122
Entity Type Code : Individual
Provider Name (Legal Business Name) : MR. GABRIEL LAMONT OLLISON PA-C
Provider Business Mailing Address
First Line : 611 WILDERNESS TRAIL DR
Second Line :
City : CHARLOTTE
State : NC
Zip : 28214-5006
Country : US
Telephone Number : 704-968-0766
Fax Number :
Provider Business Practice Location Address
First Line : 203 SALISBURY ST
Second Line :
City : WADESBORO
State : NC
Zip : 28170-2155
Country : US
Telephone Number : 704-694-6700
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 01/10/2021
Last Update Date : 01/10/2021

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