Provider Demographics
NPI:1619087640
Name:ELEY-HARDY, KATINA (PAC)
Entity Type:Individual
Prefix:MS
First Name:KATINA
Middle Name:
Last Name:ELEY-HARDY
Suffix:
Gender:F
Credentials:PAC
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 669
Mailing Address - Street 2:
Mailing Address - City:AHOSKIE
Mailing Address - State:NC
Mailing Address - Zip Code:27910-0669
Mailing Address - Country:US
Mailing Address - Phone:252-209-0237
Mailing Address - Fax:252-209-0197
Practice Address - Street 1:120 HEALTH CENTER DR
Practice Address - Street 2:
Practice Address - City:AHOSKIE
Practice Address - State:NC
Practice Address - Zip Code:27910-8161
Practice Address - Country:US
Practice Address - Phone:252-332-3548
Practice Address - Fax:252-332-1665
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2016-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC102844363A00000X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8101658Medicaid
NCP74623Medicare UPIN