Provider Demographics
NPI:1760506307
Name:KONIGSBERG, AUDREY JALAINE (PA)
Entity Type:Individual
Prefix:MS
First Name:AUDREY
Middle Name:JALAINE
Last Name:KONIGSBERG
Suffix:
Gender:F
Credentials:PA
Other - Prefix:MS
Other - First Name:AUDREY
Other - Middle Name:JALAINE
Other - Last Name:CRIPE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:355 SOURWOOD MOUNTAIN DR
Mailing Address - Street 2:
Mailing Address - City:MURPHY
Mailing Address - State:NC
Mailing Address - Zip Code:28906-4559
Mailing Address - Country:US
Mailing Address - Phone:828-494-9694
Mailing Address - Fax:828-494-9696
Practice Address - Street 1:430 RANKIN DR
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:NC
Practice Address - Zip Code:28752-6568
Practice Address - Country:US
Practice Address - Phone:828-659-5175
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-19
Last Update Date:2010-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC103511363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCP85485Medicare UPIN
NC2763530Medicare ID - Type Unspecified