Provider Demographics
NPI:1003206434
Name:OCCHIBOI, EMIL PETER (PA-C, ATC)
Entity type:Individual
Prefix:
First Name:EMIL
Middle Name:PETER
Last Name:OCCHIBOI
Suffix:
Gender:M
Credentials:PA-C, ATC
Other - Prefix:
Other - First Name:EJ
Other - Middle Name:
Other - Last Name:OCCHIBOI
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 60447
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-0447
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4741 RANDOLPH RD STE 100&200
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28211-2919
Practice Address - Country:US
Practice Address - Phone:704-365-6730
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-01-22
Last Update Date:2025-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0009072255A2300X
CT23.004688363AS0400X
NC0010-08548363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic TrainerGroup - Single Specialty
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCNN5848AMedicaid