Individual
BRENT CHARLES DEATHERAGE
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
PA-C
Contact information
Practice address
1900 RANDOLPH RD, SUITE 900, CHARLOTTE, NC 28207-1122
(704) 377-2424
(704) 377-2687
Mailing address
1900 RANDOLPH RD, SUITE 900, CHARLOTTE, NC 28207-1122
(704) 377-2424
(704) 377-2687
Taxonomy
Speciality
Code
Description
License number
State
363AM0700X
Medical Physician Assistant
Primary
0010-03428
NC
363AS0400X
Surgical Physician Assistant
PA9104956
FL
Other
Enumeration date
05/06/2009
Last updated
08/10/2012
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