Provider Demographics
NPI:1952314858
Name:JANDEBEUR, RONALD KIMERLEE (NP)
Entity Type:Individual
Prefix:
First Name:RONALD
Middle Name:KIMERLEE
Last Name:JANDEBEUR
Suffix:
Gender:M
Credentials:NP
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 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:704-316-0438
Mailing Address - Fax:704-316-4847
Practice Address - Street 1:6231 FAIRVIEW RD
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28210-3262
Practice Address - Country:US
Practice Address - Phone:704-316-0438
Practice Address - Fax:704-316-0439
Is Sole Proprietor?:No
Enumeration Date:2006-08-14
Last Update Date:2024-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC200352363L00000X
NC21496363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
S63541Medicare UPIN
2598053CMedicare PIN