Healthcare Provider Details

I. General information

NPI: 1104364918
Provider Name (Legal Business Name): URSULA TREADAWAY PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/01/2017
Last Update Date: 12/11/2019
Certification Date: 12/11/2019
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3609 OUTDOOR SPORTSMAN PL STE 7
KODAK TN
37764-1477
US

IV. Provider business mailing address

PO BOX 3439
NORTH MYRTLE BEACH SC
29582-0439
US

V. Phone/Fax

Practice location:
  • Phone: 652-815-9228
  • Fax: 865-766-5396
Mailing address:
  • Phone: 843-839-4447
  • Fax: 843-399-0123

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: