Provider Demographics
NPI:1629153846
Name:DE BARROS, JEAN MARIE (PA)
Entity Type:Individual
Prefix:
First Name:JEAN MARIE
Middle Name:
Last Name:DE BARROS
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 1:16147 LANCASTER HWY
Mailing Address - Street 2:SUITE 120
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28277-2050
Mailing Address - Country:US
Mailing Address - Phone:704-243-7106
Mailing Address - Fax:
Practice Address - Street 1:16147 LANCASTER HWY
Practice Address - Street 2:SUITE 120
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28277-2050
Practice Address - Country:US
Practice Address - Phone:704-243-7106
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-26
Last Update Date:2012-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-02161363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant