Provider Demographics
NPI:1023814142
Name:VELAZQUEZ HERNANDEZ, MAITE MISHEL (PA-C)
Entity type:Individual
Prefix:MRS
First Name:MAITE
Middle Name:MISHEL
Last Name:VELAZQUEZ HERNANDEZ
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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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:
Mailing Address - Fax:
Practice Address - Street 1:1904 JAKE ALEXANDER BLVD W STE 301
Practice Address - Street 2:
Practice Address - City:SALISBURY
Practice Address - State:NC
Practice Address - Zip Code:28147-1177
Practice Address - Country:US
Practice Address - Phone:704-797-2442
Practice Address - Fax:704-797-2443
Is Sole Proprietor?:Yes
Enumeration Date:2025-02-20
Last Update Date:2025-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X
NC0010-15231363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant