Provider Demographics
NPI:1497715742
Name:FISHBURNE, GINA M (PA)
Entity Type:Individual
Prefix:MS
First Name:GINA
Middle Name:M
Last Name:FISHBURNE
Suffix:
Gender:F
Credentials:PA
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:704-384-1775
Mailing Address - Fax:704-384-1776
Practice Address - Street 1:19485 OLD JETTON RD STE 100
Practice Address - Street 2:
Practice Address - City:CORNELIUS
Practice Address - State:NC
Practice Address - Zip Code:28031-6583
Practice Address - Country:US
Practice Address - Phone:704-384-1775
Practice Address - Fax:704-384-1776
Is Sole Proprietor?:No
Enumeration Date:2006-03-23
Last Update Date:2015-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCNC 102864363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC0243PAMedicaid
NCD7502OtherMEDCOST
SC0243PAMedicaid
P49390Medicare UPIN
P00092228Medicare ID - Type UnspecifiedRAILROAD