Basic Information
| Provider Information | |||||||||
| NPI: | 1104364918 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | TREADAWAY | ||||||||
| FirstName: | URSULA | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 3439 | ||||||||
| Address2: | |||||||||
| City: | NORTH MYRTLE BEACH | ||||||||
| State: | SC | ||||||||
| PostalCode: | 295820439 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8438394447 | ||||||||
| FaxNumber: | 8433990123 | ||||||||
| Practice Location | |||||||||
| Address1: | 3609 OUTDOOR SPORTSMAN PL STE 7 | ||||||||
| Address2: | |||||||||
| City: | KODAK | ||||||||
| State: | TN | ||||||||
| PostalCode: | 377641477 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6528159228 | ||||||||
| FaxNumber: | 8657665396 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/01/2017 | ||||||||
| LastUpdateDate: | 12/11/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/11/2019 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical | 363A00000X | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.