Provider Demographics
NPI:1891008652
Name:CIOVACCO, EMILY C (PA-C)
Entity Type:Individual
Prefix:
First Name:EMILY
Middle Name:C
Last Name:CIOVACCO
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:EMILY
Other - Middle Name:C
Other - Last Name:FEAUVE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:PO BOX 60447
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-0447
Mailing Address - Country:US
Mailing Address - Phone:704-384-7680
Mailing Address - Fax:
Practice Address - Street 1:14215 BALLANTYNE CORPORATE PL
Practice Address - Street 2:SUITE 230
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28277-3670
Practice Address - Country:US
Practice Address - Phone:704-316-5000
Practice Address - Fax:704-316-5010
Is Sole Proprietor?:No
Enumeration Date:2010-07-22
Last Update Date:2017-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY014096363A00000X
NC0010-04419363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY1891008652Medicaid
NC1891008652Medicaid
SC1710PAMedicaid
NY1891008652Medicaid
NC1891008652Medicaid