Basic Information
Provider Information | |||||||||
NPI: | 1174925952 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | STANBERY | ||||||||
FirstName: | MARY | ||||||||
MiddleName: | LINDSEY | ||||||||
NamePrefix: | MRS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | PA-C | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | ANTON | ||||||||
OtherFirstName: | MARY | ||||||||
OtherMiddleName: | LINDSEY | ||||||||
OtherNamePrefix: | MS. | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 1130 N CHURCH ST | ||||||||
Address2: | SUITE 100 | ||||||||
City: | GREENSBORO | ||||||||
State: | NC | ||||||||
PostalCode: | 274011038 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3363752300 | ||||||||
FaxNumber: | 3363752314 | ||||||||
Practice Location | |||||||||
Address1: | 1211 VIRGINIA ST | ||||||||
Address2: |   | ||||||||
City: | GREENSBORO | ||||||||
State: | NC | ||||||||
PostalCode: | 274011313 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3362750927 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/23/2014 | ||||||||
LastUpdateDate: | 08/25/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 08/25/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 0010-05279 | NC | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |   |
No ID Information.