Provider Demographics
NPI:1407822273
Name:HAYES, KATHLEEN (PAC)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:
Last Name:HAYES
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:KATHLEEN
Other - Middle Name:A
Other - Last Name:CUSTRINI
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PA
Mailing Address - Street 1:6300 TRIPP PL
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28277-0103
Mailing Address - Country:US
Mailing Address - Phone:704-577-5656
Mailing Address - Fax:704-544-0357
Practice Address - Street 1:6300 TRIPP PL
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28277-0103
Practice Address - Country:US
Practice Address - Phone:704-577-5656
Practice Address - Fax:704-544-0357
Is Sole Proprietor?:No
Enumeration Date:2006-02-23
Last Update Date:2013-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC103463363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC2762158Medicare PIN