Provider Demographics
NPI:1003862558
Name:BUCHANAN, MISTY ANN (PA)
Entity Type:Individual
Prefix:
First Name:MISTY
Middle Name:ANN
Last Name:BUCHANAN
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: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:704-384-7840
Mailing Address - Fax:
Practice Address - Street 1:2800 DARROW RD
Practice Address - Street 2:
Practice Address - City:WALKERTOWN
Practice Address - State:NC
Practice Address - Zip Code:27051-9206
Practice Address - Country:US
Practice Address - Phone:336-595-3699
Practice Address - Fax:336-595-3193
Is Sole Proprietor?:No
Enumeration Date:2006-05-26
Last Update Date:2020-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC103025363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8101546Medicaid
NCP74564Medicare UPIN
NC2756343EMedicare UPIN
NC8101546Medicaid
NC2756343FMedicare PIN
NC2756343DMedicare PIN
NC2756343BMedicare PIN
NCNC9612AMedicare PIN