Healthcare Provider Details

I. General information

NPI: 1457064586
Provider Name (Legal Business Name): KENNETH MAURICE CUEVAS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/04/2023
Last Update Date: 10/30/2025
Certification Date: 10/30/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2301 ROBESON ST STE 301
FAYETTEVILLE NC
28305-5641
US

IV. Provider business mailing address

2301 ROBESON ST STE 301
FAYETTEVILLE NC
28305-5641
US

V. Phone/Fax

Practice location:
  • Phone: 910-484-4100
  • Fax:
Mailing address:
  • Phone: 910-484-4100
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number0010-13993
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: