Provider Demographics
NPI:1306269477
Name:SPONSELLER, DENISE WIBRAN (MPAS, PA-C)
Entity type:Individual
Prefix:
First Name:DENISE
Middle Name:WIBRAN
Last Name:SPONSELLER
Suffix:
Gender:F
Credentials:MPAS, PA-C
Other - Prefix:
Other - First Name:ELLEN
Other - Middle Name:DENISE
Other - Last Name:WIBRAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MPAS, PA-C
Mailing Address - Street 1:2920 HIGHWOODS BLVD
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27604-0010
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:811 US 70 HWY W
Practice Address - Street 2:
Practice Address - City:GARNER
Practice Address - State:NC
Practice Address - Zip Code:27529-2541
Practice Address - Country:US
Practice Address - Phone:919-235-6565
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-01-27
Last Update Date:2021-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCMPA.2046363A00000X
NC0010-04822363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant