Basic Information
| Provider Information | |||||||||
| NPI: | 1003217332 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | AMILCKA | ||||||||
| FirstName: | SHELDA | ||||||||
| MiddleName: | |||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 60447 | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282600447 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7043165000 | ||||||||
| FaxNumber: | 7043165010 | ||||||||
| Practice Location | |||||||||
| Address1: | 1900 RANDOLPH RD STE 300 | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282071106 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7043846225 | ||||||||
| FaxNumber: | 7043163825 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/05/2014 | ||||||||
| LastUpdateDate: | 10/25/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/06/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 0010-05218 | NC | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 1003217332 | 05 | NC | MEDICAID |