Basic Information
| Provider Information | |||||||||
| NPI: | 1588626915 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HARRELSON | ||||||||
| FirstName: | AMY | ||||||||
| MiddleName: | FALES | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PA-C | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | FALES | ||||||||
| OtherFirstName: | AMY | ||||||||
| OtherMiddleName: | UPCHURCH | ||||||||
| OtherNamePrefix: | MRS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | PA-C | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 221249 | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282221249 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7043321291 | ||||||||
| FaxNumber: | 7043325206 | ||||||||
| Practice Location | |||||||||
| Address1: | 3623 LATROBE DR | ||||||||
| Address2: | SUITE 216 | ||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 28211 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7043321291 | ||||||||
| FaxNumber: | 7043325206 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/03/2006 | ||||||||
| LastUpdateDate: | 09/12/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 09/12/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 103935 | NC | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 2085R0204X | 103935 | NC | N | Allopathic & Osteopathic Physicians | Radiology | Vascular & Interventional Radiology |
No ID Information.