Basic Information
| Provider Information | |||||||||
| NPI: | 1942633433 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | EGBERS | ||||||||
| FirstName: | KATIE | ||||||||
| MiddleName: | MANTIE | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 501 S SHARON AMITY RD STE 300 | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282110035 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7043772424 | ||||||||
| FaxNumber: | 7043772687 | ||||||||
| Practice Location | |||||||||
| Address1: | 501 S SHARON AMITY RD STE 300 | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282110035 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7043772424 | ||||||||
| FaxNumber: | 7043772687 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/20/2013 | ||||||||
| LastUpdateDate: | 12/03/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363AM0700X | 0010-06659 | NC | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
ID Information
| ID | Type | State | Issuer | Description | 1942633433 | 05 | NC | MEDICAID |