Provider Demographics
NPI:1407095631
Name:KORTESIS, ATHENA MARKELLA (NURSE PRACTITIONER)
Entity Type:Individual
Prefix:MS
First Name:ATHENA
Middle Name:MARKELLA
Last Name:KORTESIS
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:ATHENA
Other - Middle Name:MARKELLA
Other - Last Name:DALBER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NURSE PRACTITIONER
Mailing Address - Street 1:10620 PARK RD
Mailing Address - Street 2:SUITE 128
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28210-0106
Mailing Address - Country:US
Mailing Address - Phone:704-542-6111
Mailing Address - Fax:704-542-1239
Practice Address - Street 1:10620 PARK RD
Practice Address - Street 2:SUITE 128
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28210-0106
Practice Address - Country:US
Practice Address - Phone:704-542-6111
Practice Address - Fax:704-542-1239
Is Sole Proprietor?:No
Enumeration Date:2009-02-11
Last Update Date:2011-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5004285363LA2200X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
P00813835OtherRAIL ROAD MEDICARE
2594342Medicare PIN