Provider Demographics
NPI:1558144865
Name:DEDIO, JEANAE ELYSE (PHYSICIAN ASSISTANT)
Entity Type:Individual
Prefix:
First Name:JEANAE
Middle Name:ELYSE
Last Name:DEDIO
Suffix:
Gender:F
Credentials:PHYSICIAN ASSISTANT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:753 MCDUFFIE DR
Mailing Address - Street 2:
Mailing Address - City:MYRTLE BEACH
Mailing Address - State:SC
Mailing Address - Zip Code:29588-5452
Mailing Address - Country:US
Mailing Address - Phone:973-647-8128
Mailing Address - Fax:
Practice Address - Street 1:2301 ERWIN RD
Practice Address - Street 2:
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27705-4699
Practice Address - Country:US
Practice Address - Phone:919-648-8111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-18
Last Update Date:2024-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-13303363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant