Provider Demographics
NPI:1992762538
Name:DEAKLE, MARY (PA-C)
Entity type:Individual
Prefix:MRS
First Name:MARY
Middle Name:
Last Name:DEAKLE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 751803
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28275-1803
Mailing Address - Country:US
Mailing Address - Phone:336-766-6473
Mailing Address - Fax:336-766-8909
Practice Address - Street 1:6301 STADIUM DR
Practice Address - Street 2:
Practice Address - City:CLEMMONS
Practice Address - State:NC
Practice Address - Zip Code:27012-8766
Practice Address - Country:US
Practice Address - Phone:336-766-6473
Practice Address - Fax:336-766-8909
Is Sole Proprietor?:No
Enumeration Date:2006-04-27
Last Update Date:2020-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC100874363AM0700X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCP00654536OtherRAILROAD MEDICARE
NC8101680Medicaid
NCP00654536OtherRAILROAD MEDICARE
NC2755610DMedicare PIN