Provider Demographics
NPI:1558967885
Name:POOLE, PRISCILLA HAUG (PA-C)
Entity type:Individual
Prefix:
First Name:PRISCILLA
Middle Name:HAUG
Last Name:POOLE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:PRISCILLA
Other - Middle Name:HELEN
Other - Last Name:HAUG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:6135 PARK SOUTH DR STE 510
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28210-0100
Mailing Address - Country:US
Mailing Address - Phone:704-749-3116
Mailing Address - Fax:
Practice Address - Street 1:1000 BLYTHE BLVD
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28203-5812
Practice Address - Country:US
Practice Address - Phone:704-355-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-10
Last Update Date:2024-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-10399363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant