Provider Demographics
NPI:1326355652
Name:HART, LORETTA ANN (PA)
Entity Type:Individual
Prefix:
First Name:LORETTA
Middle Name:ANN
Last Name:HART
Suffix:
Gender:F
Credentials:PA
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 60447
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-0447
Mailing Address - Country:US
Mailing Address - Phone:704-384-7840
Mailing Address - Fax:704-384-7830
Practice Address - Street 1:449 N WENDOVER RD
Practice Address - Street 2:SUITE A
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28211-1064
Practice Address - Country:US
Practice Address - Phone:704-365-6730
Practice Address - Fax:704-365-6731
Is Sole Proprietor?:No
Enumeration Date:2010-09-08
Last Update Date:2020-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9105523363A00000X
NC0010-02440363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC0010-02440OtherPHYSICIAN ASSISTANT LICENSE
FLPA9105523OtherLICENSE