Basic Information
| Provider Information | |||||||||
| NPI: | 1174850713 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | NASH | ||||||||
| FirstName: | ANGELA | ||||||||
| MiddleName: | NICOLE | ||||||||
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| Credential: | PAC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 221249 | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282221249 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9802081704 | ||||||||
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| Practice Location | |||||||||
| Address1: | 700 E MOREHEAD ST | ||||||||
| Address2: | STE 300 | ||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282022788 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7043347800 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/03/2009 | ||||||||
| LastUpdateDate: | 04/11/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/11/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | 0010-01932 | NC | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical | 363AM0700X | PA 1591 | SC | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical | 363A00000X | 0010-01932 | NC | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 0912PA | 05 | SC | MEDICAID |