Basic Information
| Provider Information | |||||||||
| NPI: | 1073956900 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KOVAL | ||||||||
| FirstName: | CHRISTINE | ||||||||
| MiddleName: | NICOLE | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 724 AUBREY BELL DR | ||||||||
| Address2: | |||||||||
| City: | MATTHEWS | ||||||||
| State: | NC | ||||||||
| PostalCode: | 281055055 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7042953550 | ||||||||
| FaxNumber: | 7042953556 | ||||||||
| Practice Location | |||||||||
| Address1: | 724 AUBREY BELL DR | ||||||||
| Address2: | |||||||||
| City: | MATTHEWS | ||||||||
| State: | NC | ||||||||
| PostalCode: | 281055055 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7042953550 | ||||||||
| FaxNumber: | 7042953556 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/10/2013 | ||||||||
| LastUpdateDate: | 04/21/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | 6727 | GA | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical | 363AM0700X | 0110005070 | VA | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical | 363A00000X | 0010-06969 | NC | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 19NLA | 01 | NC | BCBSNC | OTHER | 5277888 | 01 | AETNA | OTHER | 2830PA | 05 | SC | MEDICAID |