Provider Demographics
NPI:1699170043
Name:PENDERGRASS, MIA
Entity type:Individual
Prefix:
First Name:MIA
Middle Name:
Last Name:PENDERGRASS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 936
Mailing Address - Street 2:EVMS MEDICAL GROUP
Mailing Address - City:NORFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23501-0936
Mailing Address - Country:US
Mailing Address - Phone:757-388-6200
Mailing Address - Fax:757-388-6201
Practice Address - Street 1:600 GRESHAM DR
Practice Address - Street 2:1100
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23507-1904
Practice Address - Country:US
Practice Address - Phone:757-388-6234
Practice Address - Fax:757-388-6201
Is Sole Proprietor?:No
Enumeration Date:2014-10-28
Last Update Date:2015-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2201001575231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAQ48554AMedicare PIN