Healthcare Provider Details

I. General information

NPI: 1689455230
Provider Name (Legal Business Name): EDNA KABISA PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/10/2023
Last Update Date: 06/17/2025
Certification Date: 06/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4420 LAKE BOONE TRL
RALEIGH NC
27607-7505
US

IV. Provider business mailing address

5221 PARAMOUNT PKWY, STE 420
MORRISVILLE NC
27560-5491
US

V. Phone/Fax

Practice location:
  • Phone: 919-784-3542
  • Fax:
Mailing address:
  • Phone: 984-974-1256
  • Fax: 984-974-1316

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number0010-13397
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number0010-13397
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: