Provider Demographics
NPI:1700052297
Name:MAIELI, BRIAN SCOTT (PA-C, ATC, CSCS)
Entity Type:Individual
Prefix:MR
First Name:BRIAN
Middle Name:SCOTT
Last Name:MAIELI
Suffix:
Gender:M
Credentials:PA-C, ATC, CSCS
Other - Prefix:
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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:336-768-9535
Mailing Address - Fax:336-768-4155
Practice Address - Street 1:19485 OLD JETTON RD
Practice Address - Street 2:SUITE 210
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27104-3769
Practice Address - Country:US
Practice Address - Phone:704-316-1830
Practice Address - Fax:704-316-1835
Is Sole Proprietor?:No
Enumeration Date:2008-05-05
Last Update Date:2020-10-26
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY011977363A00000X
NC0010-07061363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant