Provider Demographics
NPI:1205135258
Name:NEWMAN, JESSICA ELEANOR (PA-C)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:ELEANOR
Last Name:NEWMAN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:E
Other - Last Name:ELDER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:PO BOX 751803
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28275-1803
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:485 VALLEY RD
Practice Address - Street 2:
Practice Address - City:MOCKSVILLE
Practice Address - State:NC
Practice Address - Zip Code:27028-2074
Practice Address - Country:US
Practice Address - Phone:336-751-8000
Practice Address - Fax:336-751-8010
Is Sole Proprietor?:No
Enumeration Date:2011-03-16
Last Update Date:2023-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC001002821363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
12242127OtherCAQH #
NC8102439Medicaid
NC8102439Medicaid