Basic Information
| Provider Information | |||||||||
| NPI: | 1407095631 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KORTESIS | ||||||||
| FirstName: | ATHENA | ||||||||
| MiddleName: | MARKELLA | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | NURSE PRACTITIONER | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | DALBER | ||||||||
| OtherFirstName: | ATHENA | ||||||||
| OtherMiddleName: | MARKELLA | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | NURSE PRACTITIONER | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 10620 PARK RD | ||||||||
| Address2: | SUITE 128 | ||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282100106 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7045426111 | ||||||||
| FaxNumber: | 7045421239 | ||||||||
| Practice Location | |||||||||
| Address1: | 10620 PARK RD | ||||||||
| Address2: | SUITE 128 | ||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282100106 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7045426111 | ||||||||
| FaxNumber: | 7045421239 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/11/2009 | ||||||||
| LastUpdateDate: | 04/07/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LA2200X | 5004285 | NC | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health | 363LF0000X | 5004285 | NC | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | P00813835 | 01 | RAIL ROAD MEDICARE | OTHER |