Basic Information
| Provider Information | |||||||||
| NPI: | 1306416029 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FORD | ||||||||
| FirstName: | CALLIE | ||||||||
| MiddleName: | ELIZABETH | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1116 ALCOTT CT | ||||||||
| Address2: | |||||||||
| City: | RALEIGH | ||||||||
| State: | NC | ||||||||
| PostalCode: | 276096043 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9199861195 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 4420 LAKE BOONE TRL | ||||||||
| Address2: | |||||||||
| City: | RALEIGH | ||||||||
| State: | NC | ||||||||
| PostalCode: | 276076599 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9197843100 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/25/2021 | ||||||||
| LastUpdateDate: | 11/24/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/24/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 0010-11745 | NC | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.