Provider Demographics
NPI:1568401966
Name:MOCK, MICHELE DIANE (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:MICHELE
Middle Name:DIANE
Last Name:MOCK
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:PO BOX 751274
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28275-1274
Mailing Address - Country:US
Mailing Address - Phone:919-620-4921
Mailing Address - Fax:
Practice Address - Street 1:1901 HILLANDALE RD
Practice Address - Street 2:
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27705-2664
Practice Address - Country:US
Practice Address - Phone:191-938-3435
Practice Address - Fax:191-938-2879
Is Sole Proprietor?:No
Enumeration Date:2006-06-05
Last Update Date:2013-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC103146363A00000X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC2753005Medicare ID - Type Unspecified
NCP18020Medicare UPIN