Provider Demographics
NPI:1730148263
Name:MARCANTONIO, CANIO THOMAS (PA)
Entity type:Individual
Prefix:MR
First Name:CANIO
Middle Name:THOMAS
Last Name:MARCANTONIO
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 751803
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28275-1803
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2915 LYNDHURST AVE
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27103-4005
Practice Address - Country:US
Practice Address - Phone:336-765-5221
Practice Address - Fax:336-765-0430
Is Sole Proprietor?:No
Enumeration Date:2006-03-22
Last Update Date:2021-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC103584363A00000X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8101544Medicaid
NCP71509Medicare UPIN
NC2757205BMedicare PIN
NC8101544Medicaid