Provider Demographics
NPI:1063795995
Name:COVERDALE, LINDA RENEE (PA)
Entity type:Individual
Prefix:MRS
First Name:LINDA
Middle Name:RENEE
Last Name:COVERDALE
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:200 QUEENS RD
Mailing Address - Street 2:SUITE 400
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28204-3253
Mailing Address - Country:US
Mailing Address - Phone:704-333-7376
Mailing Address - Fax:704-333-3397
Practice Address - Street 1:200 QUEENS RD
Practice Address - Street 2:SUITE 400
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28204-3253
Practice Address - Country:US
Practice Address - Phone:704-333-7376
Practice Address - Fax:704-333-3397
Is Sole Proprietor?:No
Enumeration Date:2011-09-27
Last Update Date:2015-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC001003106363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC232009OtherMEDICARE PTAN GROUP, CMCNE
NCNC2734DMedicare PIN
NCNC2734CMedicare PIN