Provider Demographics
NPI:1306821269
Name:THIEBAUD, EUGENE HENRY (PAC)
Entity Type:Individual
Prefix:
First Name:EUGENE
Middle Name:HENRY
Last Name:THIEBAUD
Suffix:
Gender:M
Credentials:PAC
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 60447
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-0447
Mailing Address - Country:US
Mailing Address - Phone:336-718-7950
Mailing Address - Fax:336-718-7989
Practice Address - Street 1:BLDG 200, ROBINHOOD MEDICAL PLAZA
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27106-5475
Practice Address - Country:US
Practice Address - Phone:336-718-7950
Practice Address - Fax:336-718-7989
Is Sole Proprietor?:No
Enumeration Date:2005-12-13
Last Update Date:2014-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC101957363A00000X
NC000101957363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
94709OtherMEDCOST
970025236OtherRR MEDICARE
7400798OtherAETNA
S14524Medicare UPIN
NC2750312BMedicare PIN