Provider Demographics
NPI:1114340163
Name:DEVANE, PATRICK B (PA-C)
Entity Type:Individual
Prefix:
First Name:PATRICK
Middle Name:B
Last Name:DEVANE
Suffix:
Gender:M
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 1:501 S SHARON AMITY RD STE 300
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28211-0035
Mailing Address - Country:US
Mailing Address - Phone:704-377-2424
Mailing Address - Fax:704-377-2687
Practice Address - Street 1:501 S SHARON AMITY RD STE 300
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28211-0035
Practice Address - Country:US
Practice Address - Phone:704-377-2424
Practice Address - Fax:704-377-2687
Is Sole Proprietor?:No
Enumeration Date:2014-01-28
Last Update Date:2018-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110004461363A00000X
NC0010-05738363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1114340163Medicaid