BRENT CHARLES DEATHERAGE PA-C
NPI 1336373257
Physician Assistant - Medical in Charlotte, NC

Q: What is the provider's specialty?

The provider's specialty is Physician Assistant with taxonomy code 363AM0700X and a focus in Medical.

Active since May 06, 2009PECOS EnrolledAccepts Medicare Assignment

1900 RANDOLPH RD, SUITE 900, CHARLOTTE, NC 28207(704) 377-2424(704) 377-2687 Get Directions Write a Review

NPPES record last updated: August 10, 2012. Verified against the NPPES registry weekly; last sync: July 19, 2026.

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About Brent Charles Deatherage Pa-c NPPES

Official registry information on file with the National Plan and Provider Enumeration System.

BRENT CHARLES DEATHERAGE PA-C (NPI 1336373257) is an individual medical provider in Charlotte, North Carolina, licensed in North Carolina (0010-03428) and active in the NPI registry since May 2009. He is enrolled in Medicare PECOS and is a graduate of Other (2008).

NPPES Registry Identity

NPI1336373257

Entity TypeIndividualMale

Primary Taxonomy363AM0700X

Provider Legal NameBRENT CHARLES DEATHERAGECredential: PA-C

Location Address1900 RANDOLPH RD, SUITE 900Charlotte, NC 28207-1122

Mailing Address1900 Randolph Rd, Suite 900Charlotte, NC 28207-1122 · (704) 377-2424 · Fax (704) 377-2687

Phone(704) 377-2424

Fax(704) 377-2687

Sole ProprietorNo

Medical School CMSOtherGraduated 2008

Enumeration DateMay 6, 2009

Last NPPES UpdateAugust 10, 2012

✔ NPI 1336373257 is a valid, active identifier and passes the ISO check-digit test.

Specialties & Licenses 2

★ Primary SpecialtyPhysician Assistant · MedicalPhysician Assistants & Advanced Practice Nursing Providers

Taxonomy Code363AM0700X

License✔ Licensed in NC · 0010-03428

Also ListedPhysician Assistant · SurgicalTaxonomy 363AS0400X · License PA9104956 (FL)

1900 RANDOLPH RD, Charlotte, NC 28207

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Medicare Participation & PECOS CMS

Medicare enrollment, assignment, and ordering and referring status from the CMS PECOS system.

Medicare Enrollment Status

✔

Enrolled in Medicare and accepts Medicare assignment

Brent Charles Deatherage Pa-c is registered in PECOS and agrees to accept the Medicare-approved amount as full payment. Medicare patients are not billed beyond the standard deductible and coinsurance.

PECOS PAC ID547312308

PECOS Enrollment IDI20190627001749

Eligible to Order & Refer✔ Part B Labs & Imaging✔ Durable Medical Equipment✔ Home Health Agency✔ Power Mobility DevicesPer the CMS Ordering and Referring file. Eligibility means Medicare pays claims that this provider orders or refers for these categories.