Provider Demographics
NPI:1164151288
Name:THOMPSON-BYRUM, GRACE ILEX (PA-C)
Entity Type:Individual
Prefix:
First Name:GRACE
Middle Name:ILEX
Last Name:THOMPSON-BYRUM
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:GRACE
Other - Middle Name:THOMPSON
Other - Last Name:BYRUM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1530 UNION RD STE A
Mailing Address - Street 2:
Mailing Address - City:GASTONIA
Mailing Address - State:NC
Mailing Address - Zip Code:28054-2201
Mailing Address - Country:US
Mailing Address - Phone:704-867-6188
Mailing Address - Fax:704-866-4437
Practice Address - Street 1:1530 UNION RD STE A
Practice Address - Street 2:
Practice Address - City:GASTONIA
Practice Address - State:NC
Practice Address - Zip Code:28054-2201
Practice Address - Country:US
Practice Address - Phone:704-867-6188
Practice Address - Fax:704-866-4437
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-06
Last Update Date:2022-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-12338363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant