Provider Demographics
NPI:1518062041
Name:AVILA, ELENA M (PA)
Entity Type:Individual
Prefix:
First Name:ELENA
Middle Name:M
Last Name:AVILA
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 1:1450 PROFESSIONAL PARK DR STE 150
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27103-1307
Mailing Address - Country:US
Mailing Address - Phone:336-724-2434
Mailing Address - Fax:
Practice Address - Street 1:120 BRAEMAR CT
Practice Address - Street 2:
Practice Address - City:PINEHURST
Practice Address - State:NC
Practice Address - Zip Code:28374-7207
Practice Address - Country:US
Practice Address - Phone:910-295-5567
Practice Address - Fax:910-295-3315
Is Sole Proprietor?:No
Enumeration Date:2006-09-13
Last Update Date:2021-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC102577363A00000X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCS61613Medicare UPIN
NC2748487BMedicare ID - Type Unspecified