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NPI Code Detail

MEDICARE: KENDRA DIAN EDGE PA

MEDICARE: KENDRA DIAN EDGE PA
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1363A00000XPhysician Assistant102842NC

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
11285682310OTHERNCWSCA GRP NPI #
2MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number : 1659351914
Entity Type Code : Individual
Provider Name (Legal Business Name) : KENDRA DIAN EDGE PA
Provider Business Mailing Address
First Line : PO BOX 751803
Second Line :
City : CHARLOTTE
State : NC
Zip : 28275-1803
Country : US
Telephone Number : 336-718-6169
Fax Number : 336-718-6190
Provider Business Practice Location Address
First Line : 2025 FRONTIS PLAZA BLVD STE 100
Second Line :
City : WINSTON SALEM
State : NC
Zip : 27103-5663
Country : US
Telephone Number : 336-718-6199
Fax Number : 336-719-6190
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 01/20/2006
Last Update Date : 07/29/2024

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1770563892 — TODD EVANS CRAWFORD PA
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1679531560 — FORSYTH MEMORIAL HOSPITAL INC
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Directions to “ KENDRA DIAN EDGE PA” Practice Location

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