Basic Information
| Provider Information | |||||||||
| NPI: | 1952724908 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MILLS | ||||||||
| FirstName: | MARLA | ||||||||
| MiddleName: | EDDINS | ||||||||
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| Credential: | MMS, PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 10628 PARK RD | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282108407 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7046677070 | ||||||||
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| Practice Location | |||||||||
| Address1: | 10628 PARK RD | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282108407 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7046677070 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/28/2014 | ||||||||
| LastUpdateDate: | 10/13/2015 | ||||||||
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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 | 0010-04802 | NC | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 1864PA | 05 | SC | MEDICAID | 1952724908 | 05 | NC | MEDICAID |