Provider Demographics
NPI:1548421001
Name:VICARIO, ELISA P (PA)
Entity Type:Individual
Prefix:MRS
First Name:ELISA
Middle Name:P
Last Name:VICARIO
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:101 DONALD ROSS DR
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27610-1805
Mailing Address - Country:US
Mailing Address - Phone:919-250-3320
Mailing Address - Fax:919-250-3322
Practice Address - Street 1:101 DONALD ROSS DR
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27610-1805
Practice Address - Country:US
Practice Address - Phone:919-250-3320
Practice Address - Fax:919-250-3322
Is Sole Proprietor?:No
Enumeration Date:2008-06-18
Last Update Date:2008-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC100882363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCLICENCE # 100882OtherNC PHYSICIAN ASSISTANT LICENCE # 100882