Provider Demographics
NPI:1790837342
Name:PAMINTUAN, GRACE CRUZ (MD)
Entity Type:Individual
Prefix:
First Name:GRACE
Middle Name:CRUZ
Last Name:PAMINTUAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10616 METROMONT PKWY
Mailing Address - Street 2:SUITE 104
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28269
Mailing Address - Country:US
Mailing Address - Phone:704-921-6659
Mailing Address - Fax:704-921-6698
Practice Address - Street 1:10616 METROMONT PKWY
Practice Address - Street 2:SUITE 104
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28269
Practice Address - Country:US
Practice Address - Phone:704-921-6659
Practice Address - Fax:704-921-6698
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-16
Last Update Date:2014-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC9700121174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC891070PMedicaid
NCG45579Medicare UPIN
NC891070PMedicaid