Provider Demographics
NPI:1033171962
Name:STAVOVY, MICHELE DEELEY (PA-C)
Entity Type:Individual
Prefix:
First Name:MICHELE
Middle Name:DEELEY
Last Name:STAVOVY
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:MICHELE
Other - Middle Name:LYNN
Other - Last Name:DEELEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:1202 MEDICAL CENTER DRIVE
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28401-7307
Mailing Address - Country:US
Mailing Address - Phone:910-341-3300
Mailing Address - Fax:910-251-8824
Practice Address - Street 1:1202 MEDICAL CENTER DRIVE
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28401-7307
Practice Address - Country:US
Practice Address - Phone:910-341-3300
Practice Address - Fax:910-251-8824
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-05
Last Update Date:2014-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-01051363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC2770570Medicare PIN
NCQ66247Medicare UPIN