Provider Demographics
NPI:1659351914
Name:EDGE, KENDRA DIAN (PA)
Entity Type:Individual
Prefix:
First Name:KENDRA
Middle Name:DIAN
Last Name:EDGE
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:PO BOX 751803
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28275-1803
Mailing Address - Country:US
Mailing Address - Phone:336-718-6169
Mailing Address - Fax:336-718-6190
Practice Address - Street 1:3333 SILAS CREEK PKWY
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27103-3013
Practice Address - Country:US
Practice Address - Phone:336-718-6169
Practice Address - Fax:336-718-6190
Is Sole Proprietor?:No
Enumeration Date:2006-01-20
Last Update Date:2023-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC102842363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8101870Medicaid
NC1285682310OtherWSCA GRP NPI #
NC1285682310OtherWSCA GRP NPI #
NCP06134Medicare UPIN
NC2759872BMedicare PIN
NC8101870Medicaid