Provider Demographics
NPI:1841787454
Name:PANEBIANCO, KEVIN CHRISTOPHER
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:CHRISTOPHER
Last Name:PANEBIANCO
Suffix:
Gender:M
Credentials:
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 936857
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:31193-6857
Mailing Address - Country:US
Mailing Address - Phone:910-300-4500
Mailing Address - Fax:910-675-3030
Practice Address - Street 1:7910 US HWY 117 S UNIT 120
Practice Address - Street 2:
Practice Address - City:ROCKY POINT
Practice Address - State:NC
Practice Address - Zip Code:28457-7409
Practice Address - Country:US
Practice Address - Phone:910-300-4500
Practice Address - Fax:910-675-3030
Is Sole Proprietor?:No
Enumeration Date:2018-04-18
Last Update Date:2021-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-08035363A00000X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty