Provider Demographics
NPI:1104338094
Name:DEPASQUALE, MICHAEL CHARLES (PA)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:CHARLES
Last Name:DEPASQUALE
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1818 RICHARDSON DR STE A
Mailing Address - Street 2:
Mailing Address - City:REIDSVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27320-5450
Mailing Address - Country:US
Mailing Address - Phone:336-349-5040
Mailing Address - Fax:
Practice Address - Street 1:1818 RICHARDSON DR STE A
Practice Address - Street 2:
Practice Address - City:REIDSVILLE
Practice Address - State:NC
Practice Address - Zip Code:27320-5450
Practice Address - Country:US
Practice Address - Phone:336-349-5040
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-10-31
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-07528363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant