Provider Demographics
NPI:1811032857
Name:ELLIOTT, EVELYN HODGE
Entity Type:Individual
Prefix:
First Name:EVELYN
Middle Name:HODGE
Last Name:ELLIOTT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:130 MERTON RD
Mailing Address - Street 2:
Mailing Address - City:LAWNDALE
Mailing Address - State:NC
Mailing Address - Zip Code:28090-9450
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:315 E GROVER ST
Practice Address - Street 2:
Practice Address - City:SHELBY
Practice Address - State:NC
Practice Address - Zip Code:28150-3919
Practice Address - Country:US
Practice Address - Phone:704-484-5100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC100014363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC100014OtherSTATE LICENSE