1043339070 NPI number — PAMELA K EDGAR WELLS OTR

Table of content: PAMELA K EDGAR WELLS OTR (NPI 1043339070)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1043339070 NPI number — PAMELA K EDGAR WELLS OTR

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
EDGAR WELLS
Provider First Name:
PAMELA
Provider Middle Name:
K
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
OTR
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
EDGAR
Provider Other First Name:
PAMELA
Provider Other Middle Name:
KAY
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
OTR
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1043339070
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/12/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5952 OLD PROVIDENCE RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHARLOTTE
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28226-6808
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
704-287-7365
Provider Business Mailing Address Fax Number:
704-364-4232

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3315 SPRINGBANK LN
Provider Second Line Business Practice Location Address:
SUITE 206
Provider Business Practice Location Address City Name:
CHARLOTTE
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28226-3197
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
704-287-7365
Provider Business Practice Location Address Fax Number:
704-341-2244
Provider Enumeration Date:
03/29/2007

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: 225XP0200X , with the licence number:  0960 , 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: 12744 . This is a "BCBS" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 7301422 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com