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NPI Code Detail

MEDICARE: ANNE THERESA VAILLANCOURT PA-C

MEDICARE: ANNE THERESA VAILLANCOURT 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 Assistant100680NC

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1100680OTHERNCMEDICAL LICENSE

General Provider Information

NPI Number : 1982763306
Entity Type Code : Individual
Provider Name (Legal Business Name) : ANNE THERESA VAILLANCOURT PA-C
Provider Business Mailing Address
First Line : PO BOX 63362
Second Line : 151 RAM'S PLAZA
City : CHARLOTTE
State : NC
Zip : 28263-3362
Country : US
Telephone Number : 919-620-4918
Fax Number : 919-620-4921
Provider Business Practice Location Address
First Line : 1728 FORDHAM BLVD
Second Line : 151 RAM'S PLAZA
City : CHAPEL HILL
State : NC
Zip : 27514-2397
Country : US
Telephone Number : 919-968-1985
Fax Number : 919-942-0038
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 12/08/2006
Last Update Date : 03/24/2016

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