Provider Demographics
NPI:1922671403
Name:GIPSON-LEROUX, MARIAH DEE (PA)
Entity type:Individual
Prefix:
First Name:MARIAH
Middle Name:DEE
Last Name:GIPSON-LEROUX
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 1:131 PROVIDENCE RD STE 200
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28207-1235
Mailing Address - Country:US
Mailing Address - Phone:980-256-2233
Mailing Address - Fax:
Practice Address - Street 1:131 PROVIDENCE RD STE 200
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28207-1235
Practice Address - Country:US
Practice Address - Phone:980-256-2233
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-21
Last Update Date:2025-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY027407OtherNYSED PHYSICIAN ASSISTANT LICENSE
NC0010-15427OtherNCMB