Provider Demographics
NPI:1104364918
Name:TREADAWAY, URSULA (PA-C)
Entity Type:Individual
Prefix:
First Name:URSULA
Middle Name:
Last Name:TREADAWAY
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 3439
Mailing Address - Street 2:
Mailing Address - City:NORTH MYRTLE BEACH
Mailing Address - State:SC
Mailing Address - Zip Code:29582-0439
Mailing Address - Country:US
Mailing Address - Phone:843-839-4447
Mailing Address - Fax:843-399-0123
Practice Address - Street 1:3609 OUTDOOR SPORTSMAN PL STE 7
Practice Address - Street 2:
Practice Address - City:KODAK
Practice Address - State:TN
Practice Address - Zip Code:37764-1477
Practice Address - Country:US
Practice Address - Phone:652-815-9228
Practice Address - Fax:865-766-5396
Is Sole Proprietor?:No
Enumeration Date:2017-02-01
Last Update Date:2019-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC3744PAMedicaid