Provider Demographics
NPI:1962698753
Name:STADELMAN, JOLIE ANN (PA-C)
Entity type:Individual
Prefix:MISS
First Name:JOLIE
Middle Name:ANN
Last Name:STADELMAN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5222 MOYE ROAD
Mailing Address - Street 2:
Mailing Address - City:TRENT WOODS
Mailing Address - State:NC
Mailing Address - Zip Code:28562-7458
Mailing Address - Country:US
Mailing Address - Phone:216-513-0791
Mailing Address - Fax:252-633-8004
Practice Address - Street 1:5222 MOYE ROAD
Practice Address - Street 2:
Practice Address - City:TRENT WOODS
Practice Address - State:NC
Practice Address - Zip Code:28562-7458
Practice Address - Country:US
Practice Address - Phone:216-513-0791
Practice Address - Fax:252-633-8004
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-14
Last Update Date:2012-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV1056363A00000X
NC0010-02241363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NVNV7279OtherBC/BS
NV1962698753Medicaid
NC0010-02241OtherNC
104863Medicare PIN