Provider Demographics
NPI:1346967734
Name:PROVENZANO, MARCELA (PA-C)
Entity type:Individual
Prefix:
First Name:MARCELA
Middle Name:
Last Name:PROVENZANO
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:MARCELA
Other - Middle Name:
Other - Last Name:HERNANDEZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:10207 CERNY ST STE 102
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27617-4880
Mailing Address - Country:US
Mailing Address - Phone:919-613-1807
Mailing Address - Fax:919-544-6907
Practice Address - Street 1:10207 CERNY ST STE 102
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27617-4880
Practice Address - Country:US
Practice Address - Phone:919-613-1807
Practice Address - Fax:919-544-6907
Is Sole Proprietor?:No
Enumeration Date:2022-10-26
Last Update Date:2025-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-12733363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant