MEDICARE: JACQUELINE MARIE SLOAN 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	0010-10871	NC
2	363AS0400X	Surgical Physician Assistant	0010-10871	NC
3	363A00000X	Physician Assistant	0010-10871	NC

General Provider Information

NPI Number	:	1871114991
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JACQUELINE MARIE SLOAN PA-C

Provider Business Mailing Address
First Line	:	3906 WAKE FOREST RD
Second Line	:
City	:	RALEIGH
State	:	NC
Zip	:	27609-6867
Country	:	US
Telephone Number	:	716-880-4413
Fax Number	:	919-350-7687

Provider Business Practice Location Address
First Line	:	3906 WAKE FOREST RD
Second Line	:
City	:	RALEIGH
State	:	NC
Zip	:	27609-6867
Country	:	US
Telephone Number	:	716-880-4413
Fax Number	:	919-350-7687

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

Provider Enumeration Date	:	04/29/2020
Last Update Date	:	10/15/2024

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