Provider Demographics
NPI:1932184611
Name:CALLIE, FAWN SERENE (PA-C)
Entity type:Individual
Prefix:MS
First Name:FAWN
Middle Name:SERENE
Last Name:CALLIE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MRS
Other - First Name:SHARON
Other - Middle Name:FAWN
Other - Last Name:CALLIE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:103 DOE COURT
Mailing Address - Street 2:
Mailing Address - City:HAMPSTEAD
Mailing Address - State:NC
Mailing Address - Zip Code:28443
Mailing Address - Country:US
Mailing Address - Phone:910-214-0475
Mailing Address - Fax:919-735-0582
Practice Address - Street 1:2707 MEDICAL OFFICE PL
Practice Address - Street 2:
Practice Address - City:GOLDSBORO
Practice Address - State:NC
Practice Address - Zip Code:27534-9458
Practice Address - Country:US
Practice Address - Phone:919-735-9146
Practice Address - Fax:919-735-0582
Is Sole Proprietor?:No
Enumeration Date:2005-12-14
Last Update Date:2023-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC101963207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCP00238952OtherRETIRED RAILROAD MEDICARE
NC2752884AMedicare ID - Type Unspecified
NCP00238952OtherRETIRED RAILROAD MEDICARE