Provider Demographics
NPI:1053869636
Name:GWYNN, IVY PALAS (PA)
Entity type:Individual
Prefix:
First Name:IVY
Middle Name:PALAS
Last Name:GWYNN
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1417 MORRIS RD
Mailing Address - Street 2:
Mailing Address - City:PITTSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27312-7718
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:101 CABARRUS AVE E STE 200
Practice Address - Street 2:
Practice Address - City:CONCORD
Practice Address - State:NC
Practice Address - Zip Code:28025-3781
Practice Address - Country:US
Practice Address - Phone:828-713-0431
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-09-13
Last Update Date:2023-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA60702355363A00000X
NC0010-12279363A00000X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1053869636Medicaid
WA1053869636Medicaid