Provider Demographics
NPI:1083121776
Name:DE SA, SHERYL MARIA SAVITA
Entity type:Individual
Prefix:
First Name:SHERYL
Middle Name:MARIA SAVITA
Last Name:DE SA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 60447
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-0447
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5325 VINNING ST NW STE 101
Practice Address - Street 2:
Practice Address - City:CONCORD
Practice Address - State:NC
Practice Address - Zip Code:28027-2956
Practice Address - Country:US
Practice Address - Phone:704-316-1040
Practice Address - Fax:704-316-1041
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-04
Last Update Date:2024-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD471281207Q00000X
NC2024-02510207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty