Provider Demographics
NPI:1831279561
Name:BAIN, JULIE BETH (PA)
Entity Type:Individual
Prefix:
First Name:JULIE
Middle Name:BETH
Last Name:BAIN
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:JULIE
Other - Middle Name:BETH
Other - Last Name:MORRIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:5350 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27107-9174
Mailing Address - Country:US
Mailing Address - Phone:336-784-0505
Mailing Address - Fax:336-784-5031
Practice Address - Street 1:5350 S MAIN ST
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27107-9174
Practice Address - Country:US
Practice Address - Phone:336-784-0505
Practice Address - Fax:336-784-5031
Is Sole Proprietor?:No
Enumeration Date:2006-10-17
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC103344363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MB0762016OtherFEDERAL DEA
P44468Medicare UPIN