Provider Demographics
NPI:1346921913
Name:ONTIVEROS, CAITLIN MICHELLE (PA-S)
Entity type:Individual
Prefix:
First Name:CAITLIN
Middle Name:MICHELLE
Last Name:ONTIVEROS
Suffix:
Gender:F
Credentials:PA-S
Other - Prefix:
Other - First Name:CAITLIN
Other - Middle Name:MICHELLE
Other - Last Name:TOMINEY
Other - Suffix:
Other - Last Name Type:Former Name
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:336-277-4075
Mailing Address - Fax:336-277-4070
Practice Address - Street 1:7210 VILLAGE MEDICAL CIR STE 310
Practice Address - Street 2:
Practice Address - City:CLEMMONS
Practice Address - State:NC
Practice Address - Zip Code:27012-8041
Practice Address - Country:US
Practice Address - Phone:336-277-4075
Practice Address - Fax:336-277-4070
Is Sole Proprietor?:No
Enumeration Date:2023-07-27
Last Update Date:2024-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363AM0700X, 363AS0400X
NC0010-14694363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical