Basic Information
| Provider Information | |||||||||
| NPI: | 1093363095 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | IVAN | ||||||||
| FirstName: | ALLISON | ||||||||
| MiddleName: | MARIE | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 645 AMALIA ST NE | ||||||||
| Address2: | |||||||||
| City: | CONCORD | ||||||||
| State: | NC | ||||||||
| PostalCode: | 280252434 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7042953255 | ||||||||
| FaxNumber: | 7042957791 | ||||||||
| Practice Location | |||||||||
| Address1: | 645 AMALIA ST NE | ||||||||
| Address2: | |||||||||
| City: | CONCORD | ||||||||
| State: | NC | ||||||||
| PostalCode: | 280252434 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7042953255 | ||||||||
| FaxNumber: | 7042957791 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/03/2019 | ||||||||
| LastUpdateDate: | 04/28/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/28/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 0010-08982 | NC | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.