Provider Demographics
NPI:1386318772
Name:ADDIS, CALLISTA ROSE (PA-C)
Entity type:Individual
Prefix:
First Name:CALLISTA
Middle Name:ROSE
Last Name:ADDIS
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:501 GREENE FARM TRL
Mailing Address - Street 2:
Mailing Address - City:VILAS
Mailing Address - State:NC
Mailing Address - Zip Code:28692-9779
Mailing Address - Country:US
Mailing Address - Phone:919-812-5303
Mailing Address - Fax:
Practice Address - Street 1:1 MEDICAL CENTER BLVD
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27157-2128
Practice Address - Country:US
Practice Address - Phone:336-716-2255
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-09
Last Update Date:2022-10-27
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NC0010-11558363A00000X
363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant