Provider Demographics
NPI:1821319070
Name:EVERIDGE, JULIE ALLISON (PA)
Entity Type:Individual
Prefix:
First Name:JULIE
Middle Name:ALLISON
Last Name:EVERIDGE
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 1:4692 BROWNSBORO RD
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27106-3410
Mailing Address - Country:US
Mailing Address - Phone:336-251-1114
Mailing Address - Fax:336-251-1115
Practice Address - Street 1:4692 BROWNSBORO RD
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27106-3410
Practice Address - Country:US
Practice Address - Phone:336-251-1114
Practice Address - Fax:336-251-1115
Is Sole Proprietor?:No
Enumeration Date:2010-06-22
Last Update Date:2011-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-02360363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC2762334Medicare PIN