Provider Demographics
NPI:1851556898
Name:EDEN, EMILEE JO (PA)
Entity Type:Individual
Prefix:
First Name:EMILEE
Middle Name:JO
Last Name:EDEN
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 1:200 MEDICAL PARK DR STE 400
Mailing Address - Street 2:
Mailing Address - City:CONCORD
Mailing Address - State:NC
Mailing Address - Zip Code:28025-0906
Mailing Address - Country:US
Mailing Address - Phone:704-786-1108
Mailing Address - Fax:704-782-1826
Practice Address - Street 1:200 MEDICAL PARK DR STE 400
Practice Address - Street 2:
Practice Address - City:CONCORD
Practice Address - State:NC
Practice Address - Zip Code:28025-0906
Practice Address - Country:US
Practice Address - Phone:704-786-1108
Practice Address - Fax:704-782-1826
Is Sole Proprietor?:No
Enumeration Date:2008-07-18
Last Update Date:2023-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-01382207Q00000X
NC001001382363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8101372Medicaid
NC275922CMedicare PIN
NC2759222Medicare PIN
NC2759222BMedicare PIN
NC8101372Medicaid