Provider Demographics
NPI:1720743354
Name:POWELL, MYCHAL KELLY (PA-C)
Entity Type:Individual
Prefix:
First Name:MYCHAL
Middle Name:KELLY
Last Name:POWELL
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5213 S ALSTON AVE
Mailing Address - Street 2:
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27713-4430
Mailing Address - Country:US
Mailing Address - Phone:919-620-4855
Mailing Address - Fax:
Practice Address - Street 1:1352 MEBANE OAKS RD
Practice Address - Street 2:
Practice Address - City:MEBANE
Practice Address - State:NC
Practice Address - Zip Code:27302-9681
Practice Address - Country:US
Practice Address - Phone:919-525-3632
Practice Address - Fax:919-563-8453
Is Sole Proprietor?:No
Enumeration Date:2021-11-08
Last Update Date:2022-02-09
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NC0010-11919363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant