Provider Demographics
NPI:1568926269
Name:BANAWAN, SHERENE FAWZY (PA-C)
Entity Type:Individual
Prefix:
First Name:SHERENE
Middle Name:FAWZY
Last Name:BANAWAN
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 1:13108 PURPLE DAWN DR
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28213-3905
Mailing Address - Country:US
Mailing Address - Phone:704-293-6482
Mailing Address - Fax:
Practice Address - Street 1:9801 KINCEY AVE
Practice Address - Street 2:
Practice Address - City:HUNTERSVILLE
Practice Address - State:NC
Practice Address - Zip Code:28078-3110
Practice Address - Country:US
Practice Address - Phone:704-947-6597
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-27
Last Update Date:2019-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-08726363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical