Provider Demographics
NPI:1598404055
Name:MANTOOTH, MACY ALEXANDRA (PA-C)
Entity Type:Individual
Prefix:MS
First Name:MACY
Middle Name:ALEXANDRA
Last Name:MANTOOTH
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 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:
Mailing Address - Fax:
Practice Address - Street 1:10479 N NC HIGHWAY 109 STE 107A
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27107-9884
Practice Address - Country:US
Practice Address - Phone:336-769-0246
Practice Address - Fax:336-769-9366
Is Sole Proprietor?:No
Enumeration Date:2022-06-02
Last Update Date:2023-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-12344363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant