Provider Demographics
NPI:1063512093
Name:PROUSE, DEBORAH MARISA (PA-C, ATC)
Entity Type:Individual
Prefix:MISS
First Name:DEBORAH
Middle Name:MARISA
Last Name:PROUSE
Suffix:
Gender:F
Credentials:PA-C, ATC
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 5105
Mailing Address - Street 2:
Mailing Address - City:BELFAST
Mailing Address - State:ME
Mailing Address - Zip Code:04915-5100
Mailing Address - Country:US
Mailing Address - Phone:919-220-5255
Mailing Address - Fax:
Practice Address - Street 1:2076 HWY 42 WEST
Practice Address - Street 2:SUITE 300
Practice Address - City:CLAYTON
Practice Address - State:NC
Practice Address - Zip Code:27520-5302
Practice Address - Country:US
Practice Address - Phone:919-220-5255
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-22
Last Update Date:2021-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
2255A2300X
NC0010-06287363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC0010-06287OtherMEDICAL LICENSE