Provider Demographics
NPI:1962642868
Name:HODGE, PANDORA M (PA)
Entity Type:Individual
Prefix:
First Name:PANDORA
Middle Name:M
Last Name:HODGE
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:PO BOX 1869
Mailing Address - Street 2:
Mailing Address - City:FLETCHER
Mailing Address - State:NC
Mailing Address - Zip Code:28732-1869
Mailing Address - Country:US
Mailing Address - Phone:828-687-5616
Mailing Address - Fax:828-650-8076
Practice Address - Street 1:436 AIRPORT ROAD
Practice Address - Street 2:SUITE 20
Practice Address - City:ARDEN
Practice Address - State:NC
Practice Address - Zip Code:28704
Practice Address - Country:US
Practice Address - Phone:407-200-2352
Practice Address - Fax:407-200-1360
Is Sole Proprietor?:No
Enumeration Date:2009-03-05
Last Update Date:2022-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA5362363A00000X
NC0010-06056363A00000X, 363AM0700X
GA018625363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA800923922AMedicaid