Provider Demographics
NPI:1780633743
Name:DESAMERO, JANET LABAYO (PA)
Entity Type:Individual
Prefix:
First Name:JANET
Middle Name:LABAYO
Last Name:DESAMERO
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:PO BOX 19305
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28219-9305
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1025 MOREHEAD MEDICAL DR
Practice Address - Street 2:STE 300
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28204-2963
Practice Address - Country:US
Practice Address - Phone:704-355-1813
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-08
Last Update Date:2023-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC102586363A00000X, 363A00000X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1780633743Medicaid
NC2750606FOtherMEDICARE PART B
SC0214PAMedicaid
NC2750606JMedicare PIN
NC2750606KMedicare PIN
SC0214PAMedicaid