Provider Demographics
NPI:1093363095
Name:IVAN, ALLISON MARIE (PA-C)
Entity Type:Individual
Prefix:
First Name:ALLISON
Middle Name:MARIE
Last Name:IVAN
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 1:645 AMALIA ST NE
Mailing Address - Street 2:
Mailing Address - City:CONCORD
Mailing Address - State:NC
Mailing Address - Zip Code:28025-2434
Mailing Address - Country:US
Mailing Address - Phone:704-295-3255
Mailing Address - Fax:704-295-7791
Practice Address - Street 1:645 AMALIA ST NE
Practice Address - Street 2:
Practice Address - City:CONCORD
Practice Address - State:NC
Practice Address - Zip Code:28025-2434
Practice Address - Country:US
Practice Address - Phone:704-295-3255
Practice Address - Fax:704-295-7791
Is Sole Proprietor?:No
Enumeration Date:2019-09-03
Last Update Date:2021-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-08982363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant