Provider Demographics
NPI:1801854302
Name:D'AVILAR, PHILIP ANTONINUS (PA)
Entity Type:Individual
Prefix:
First Name:PHILIP
Middle Name:ANTONINUS
Last Name:D'AVILAR
Suffix:
Gender:M
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 1:613 E ROOSEVELT BLVD
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:NC
Practice Address - Zip Code:28112-5124
Practice Address - Country:US
Practice Address - Phone:704-283-8193
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-03
Last Update Date:2023-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC103028363A00000X
SC418363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1801854302Medicaid
SCAM0516Medicaid
NC8102102Medicaid
NC2759013KMedicare PIN
NC2759013RMedicare PIN
NC2759013DMedicare PIN
NC2759013GMedicare PIN
NC2759013MMedicare PIN
SCAA69007772Medicare PIN
NC8102102Medicaid
NC2759013LMedicare PIN
NC2759013NMedicare PIN
SCAM0516Medicaid
NC2759013HMedicare PIN
NC2759013BMedicare PIN
P22412Medicare UPIN
NC2759013EMedicare PIN
NC2759013FMedicare PIN
NC2759013CMedicare PIN
NC2759013AMedicare PIN
NC2759013Medicare PIN