Basic Information
| Provider Information | |||||||||
| NPI: | 1750304069 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DONALD | ||||||||
| FirstName: | KAREN | ||||||||
| MiddleName: | D | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | PA-C | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 601643 | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282601643 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7043555100 | ||||||||
| FaxNumber: | 7043555180 | ||||||||
| Practice Location | |||||||||
| Address1: | 1001 BLYTHE BLVD | ||||||||
| Address2: | SUITE 500 | ||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282035863 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7043555100 | ||||||||
| FaxNumber: | 7043555180 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/26/2006 | ||||||||
| LastUpdateDate: | 01/09/2017 | ||||||||
| 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 | 207R00000X | 100549 | NC | N | Allopathic & Osteopathic Physicians | Internal Medicine | 363A00000X | 1434 | SC | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363A00000X | 100549 | NC | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 0884PA | 05 | SC | MEDICAID | 1750304069 | 05 | NC | MEDICAID | 8101103 | 05 | NC | MEDICAID |