Provider Demographics
NPI:1033158548
Name:BLACK, NEICOLE DUTTON (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:NEICOLE
Middle Name:DUTTON
Last Name:BLACK
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MRS
Other - First Name:NEICOLE
Other - Middle Name:
Other - Last Name:BLACK
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PA-C
Mailing Address - Street 1:60 COMMERCE PLAZA CIR
Mailing Address - Street 2:
Mailing Address - City:PEMBROKE
Mailing Address - State:NC
Mailing Address - Zip Code:28372-7386
Mailing Address - Country:US
Mailing Address - Phone:910-521-2900
Mailing Address - Fax:910-775-9165
Practice Address - Street 1:2410 HOFFMEYER RD
Practice Address - Street 2:
Practice Address - City:FLORENCE
Practice Address - State:SC
Practice Address - Zip Code:29501-7311
Practice Address - Country:US
Practice Address - Phone:843-882-6162
Practice Address - Fax:843-662-8183
Is Sole Proprietor?:No
Enumeration Date:2006-06-06
Last Update Date:2019-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1091363AM0700X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8103286Medicaid
SC1091OtherSTATE LICENSE NUMBER
SCQ64865Medicare UPIN
NCNCB383AMedicare PIN