NPIMap

Individual provider Active NPI

Gaelyn Elliott Young Krickovic, PA

  • Physician Assistant
  • Kernersville, NC
National Provider Identifier
1194594036
Registry record updated Aug 22, 2024
On this page

Key facts

NPPES NPI Registry
Primary specialty
Physician AssistantTaxonomy code 363A00000X
License
0010-14225 Issued in NC
Practice address
1730 Kernersville Medical Pkwy Ste 104
Kernersville, NC 27284-7198
Phone
(336) 765-5470
Fax
(336) 499-5428
NPI assigned
Dec 20, 2023
Sex
Female
Sole proprietor
Yes

NPPES NPI Registry

Updated by the provider on Aug 22, 2024

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 3

Specialty (taxonomy)CodeLicenseStatePrimary
Physician Assistant 363A00000X
Pediatric Nurse Practitioner 363LP0200X 5019933 NC
Physician Assistant 363A00000X 0010-14225 NC Primary

Addresses

Primary practice location

1730 Kernersville Medical Pkwy Ste 104
Kernersville, NC 27284-7198

Mailing address

PO Box 60447
Charlotte, NC 28260-0447

Other practice location 1

525 N 21st St
Richmond, VA 23223-7258
Phone (757) 406-3245

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in NC
Eligible to order & refer
  • Part B services
  • Medical equipment
  • Home health
  • Power mobility devices
  • Hospice
Green means eligible to order or refer.

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
I20240710002522 NC Practitioner - Physician Assistant 0547705972 Reassigns benefits to 1 organization

Care Compare profile

Medicare Care Compare
Specialty
Physician Assistant
Education
Other, 2023
Medicare assignment
Accepts the Medicare-approved amount as payment in full
Group practices
Novant Health Medical Group, LLCGroup PAC ID 1153234893, 2,413 clinicians

Practice addresses (Care Compare)

1730 Kernersville Medical Pkwy
Kernersville, NC 27284-7198

2825 Lyndhurst Ave
Winston Salem, NC 27103-4146

3641 Westgate Ctr Cir
Suite a
Winston Salem, NC 27103-4146
Phone (704) 384-8200

National Provider Directory

National Provider Directory
Medicare enrollment (NPD)
Enrolled
Credentials
Physician Assistant

State licenses

LicenseStateTypeSpecialty
0010-14225NCMDPhysician Assistant
5019933NCMDPediatric Nurse Practitioner

Practice roles

OrganizationSpecialtyStatusNew patients
Novant Health Medical Group, LLC CurrentSince May 3, 2024 Accepting new patients
Novant Medical Group, Inc. CurrentSince May 3, 2024 Accepting new patients
Novant Health Medical Group, LLC Past Accepting new patients

Locations

5145 Sellers Rd
Shallotte, NC 28470
Phone (910) 754-4441

114 Charlois Blvd
Winston Salem, NC 27103

2825 Lyndhurst Ave
Ste 101
Winston Salem, NC 27103
Phone (336) 277-6300

Interoperability endpoints

  • Direct secure messaging: gkrickovic1353933@direct.novanthealth.org

Organizations & group practices 17

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.

View all 17

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1703030400000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1724284800000",
    "number": "1194594036",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 60447",
            "city": "CHARLOTTE",
            "state": "NC",
            "postal_code": "282600447"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1730 KERNERSVILLE MEDICAL PKWY STE 104",
            "city": "KERNERSVILLE",
            "state": "NC",
            "postal_code": "272847198",
            "telephone_number": "336-765-5470",
            "fax_number": "336-499-5428"
        }
    ],
    "practiceLocations": [
        {
            "address_1": "525 N 21st St",
            "address_purpose": "LOCATION",
            "city": "Richmond",
            "state": "VA",
            "postal_code": "232237258",
            "country_code": "US",
            "telephone_number": "757-406-3245",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "basic": {
        "last_name": "KRICKOVIC",
        "first_name": "GAELYN",
        "middle_name": "ELLIOTT YOUNG",
        "name_prefix": "Mrs.",
        "credential": "PA",
        "sole_proprietor": "YES",
        "sex": "F",
        "enumeration_date": "2023-12-20",
        "last_updated": "2024-08-22",
        "certification_date": "2024-08-22",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "363A00000X",
            "taxonomy_group": "",
            "desc": "Physician Assistant",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "363LP0200X",
            "taxonomy_group": "",
            "desc": "Nurse Practitioner, Pediatrics",
            "state": "NC",
            "license": "5019933",
            "primary": false
        },
        {
            "code": "363A00000X",
            "taxonomy_group": "",
            "desc": "Physician Assistant",
            "state": "NC",
            "license": "0010-14225",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Kernersville, NC

Sources for this page

Verify at the official NPI Registry.