Provider Demographics
NPI:1215177878
Name:MAYO, MICHELLE LEWIS (PA-C)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:LEWIS
Last Name:MAYO
Suffix:
Gender:F
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 1:509 FLAGLER DR
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28411-7269
Mailing Address - Country:US
Mailing Address - Phone:336-669-0688
Mailing Address - Fax:
Practice Address - Street 1:1717 SHIPYARD BLVD
Practice Address - Street 2:SUITE 220
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28401-8023
Practice Address - Country:US
Practice Address - Phone:910-254-9464
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-02-23
Last Update Date:2014-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC001001709363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical