Provider Demographics
NPI:1053669663
Name:SHIRLEY ELEE, LAVETTE M (PA-C)
Entity Type:Individual
Prefix:MS
First Name:LAVETTE
Middle Name:M
Last Name:SHIRLEY ELEE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 602148
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-2148
Mailing Address - Country:US
Mailing Address - Phone:704-631-1820
Mailing Address - Fax:704-825-5443
Practice Address - Street 1:420 PARK ST
Practice Address - Street 2:
Practice Address - City:BELMONT
Practice Address - State:NC
Practice Address - Zip Code:28012-3393
Practice Address - Country:US
Practice Address - Phone:704-631-1820
Practice Address - Fax:704-825-5443
Is Sole Proprietor?:No
Enumeration Date:2012-08-29
Last Update Date:2016-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-03734363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC1491PAMedicaid
NC1053669663Medicaid
NCNC8664DMedicare PIN
NCNC8664EMedicare PIN
NCNC8664FMedicare PIN
NC1053669663Medicaid
NCNC8664CMedicare PIN
NCNC86640386Medicare PIN