Provider Demographics
NPI:1316577737
Name:MAULE, JACEY B (PA-C)
Entity type:Individual
Prefix:
First Name:JACEY
Middle Name:B
Last Name:MAULE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:JACEY
Other - Middle Name:ELIZABETH
Other - Last Name:BYERS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:700 HAWES CT APT C
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27608-1745
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:241 CORPORATE BLVD STE 210
Practice Address - Street 2:
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23502-4965
Practice Address - Country:US
Practice Address - Phone:757-622-2200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-24
Last Update Date:2024-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC257016363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA011008172OtherVA MEDICAL LICENSE