Provider Demographics
NPI:1528619111
Name:RAKEBRAND, ATHENA (PA)
Entity type:Individual
Prefix:
First Name:ATHENA
Middle Name:
Last Name:RAKEBRAND
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:705 GRIFFITH ST STE 301
Mailing Address - Street 2:
Mailing Address - City:DAVIDSON
Mailing Address - State:NC
Mailing Address - Zip Code:28036-9308
Mailing Address - Country:US
Mailing Address - Phone:704-237-4240
Mailing Address - Fax:704-785-8304
Practice Address - Street 1:705 GRIFFITH ST STE 301
Practice Address - Street 2:
Practice Address - City:DAVIDSON
Practice Address - State:NC
Practice Address - Zip Code:28036-9308
Practice Address - Country:US
Practice Address - Phone:704-237-4240
Practice Address - Fax:704-785-8304
Is Sole Proprietor?:No
Enumeration Date:2019-09-25
Last Update Date:2023-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT4606363A00000X
NC001012879363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC001012879OtherNC LICENSE
ORPA202542OtherOREGON PA LICENSE
CT4606OtherPA LICENSE