Healthcare Provider Details

I. General information

NPI: 1730266453
Provider Name (Legal Business Name): MARY LEE CUDD PAC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/01/2006
Last Update Date: 01/24/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1774 METROMEDICAL DRIVE
FAYETTEVILLE NC
28304
US

IV. Provider business mailing address

1774 METROMEDICAL DRIVE
FAYETTEVILLE NC
28304
US

V. Phone/Fax

Practice location:
  • Phone: 910-323-1203
  • Fax: 910-323-3101
Mailing address:
  • Phone: 910-323-1203
  • Fax: 910-323-3101

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number0100900
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: