Basic Information
Provider Information | |||||||||
NPI: | 1437154093 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | HULL | ||||||||
FirstName: | JENNIFER | ||||||||
MiddleName: | MARIE | ||||||||
NamePrefix: | MRS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | PA-C | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 149 PLANTATION RIDGE DR | ||||||||
Address2: | SUITE 190 | ||||||||
City: | MOORESVILLE | ||||||||
State: | NC | ||||||||
PostalCode: | 281179174 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7046580595 | ||||||||
FaxNumber: | 7046580916 | ||||||||
Practice Location | |||||||||
Address1: | 6035 FAIRVIEW RD | ||||||||
Address2: |   | ||||||||
City: | CHARLOTTE | ||||||||
State: | NC | ||||||||
PostalCode: | 282103256 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7042953000 | ||||||||
FaxNumber: | 7042953468 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/20/2005 | ||||||||
LastUpdateDate: | 07/17/2017 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | MA051750 | PA | N |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |   | 363A00000X | 0010-06357 | NC | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |   |
ID Information
ID | Type | State | Issuer | Description | 19HS5 | 01 | NC | BCBS | OTHER | NCS417A | 01 | NC | MEDICARE | OTHER | 1669926 | 01 | PA | BLUE SHIELD | OTHER | P00170527 | 01 | PA | RR MEDICARE | OTHER | P01848168 | 01 | NC | RAILROAD MEDICARE | OTHER | 2601PA | 05 | SC |   | MEDICAID |