MEDICARE: KEVIN CHRISTOPHER PANEBIANCO

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	0010-08035	NC

General Provider Information

NPI Number	:	1841787454
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KEVIN CHRISTOPHER PANEBIANCO

Provider Business Mailing Address
First Line	:	PO BOX 936857
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	31193-6857
Country	:	US
Telephone Number	:	910-300-4500
Fax Number	:	910-675-3030

Provider Business Practice Location Address
First Line	:	7910 US HWY 117 S UNIT 120
Second Line	:
City	:	ROCKY POINT
State	:	NC
Zip	:	28457-7409
Country	:	US
Telephone Number	:	910-300-4500
Fax Number	:	910-675-3030

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

Provider Enumeration Date	:	04/18/2018
Last Update Date	:	05/27/2021

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