Provider Demographics
NPI:1457869240
Name:SKINNER, MITCHELL SHANE (PA-C)
Entity Type:Individual
Prefix:
First Name:MITCHELL
Middle Name:SHANE
Last Name:SKINNER
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3637 CAPE CENTER DR
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28304-4457
Mailing Address - Country:US
Mailing Address - Phone:910-491-1760
Mailing Address - Fax:910-491-1764
Practice Address - Street 1:3637 CAPE CENTER DR
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28304-4457
Practice Address - Country:US
Practice Address - Phone:910-491-1760
Practice Address - Fax:910-491-1764
Is Sole Proprietor?:No
Enumeration Date:2018-01-16
Last Update Date:2018-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-07788363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant