Basic Information
| Provider Information | |||||||||
| NPI: | 1386605640 | ||||||||
| EntityType: | 1 | ||||||||
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| LastName: | CHRISTINE | ||||||||
| FirstName: | CYBELE | ||||||||
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| Credential: | P.A. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 602658 | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282602658 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3367162011 | ||||||||
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| Practice Location | |||||||||
| Address1: | MEDICAL CENTER BLVD | ||||||||
| Address2: | |||||||||
| City: | WINSTON SALEM | ||||||||
| State: | NC | ||||||||
| PostalCode: | 271570001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3367166674 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/28/2006 | ||||||||
| LastUpdateDate: | 07/22/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA 3651 | FL | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363A00000X | PA-090 | NM | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363AS0400X | 0010-03703 | NC | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical |
ID Information
| ID | Type | State | Issuer | Description | MC1724005 | 01 | NM | DEA | OTHER |