1689455230 NPI number — EDNA KABISA PA-C

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1689455230 NPI number — EDNA KABISA PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KABISA
Provider First Name:
EDNA
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PA-C
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1689455230
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/17/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5221 PARAMOUNT PKWY, STE 420
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MORRISVILLE
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
27560-5491
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
984-974-1256
Provider Business Mailing Address Fax Number:
984-974-1316

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4420 LAKE BOONE TRL
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
RALEIGH
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
27607-7505
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
919-784-3542
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/10/2023

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363AM0700X , with the licence number:  0010-13397 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363A00000X , with the licence number: 0010-13397 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1689455230 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".




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