Healthcare Provider Details

I. General information

NPI: 1578103636
Provider Name (Legal Business Name): MADELYN LAINE EUDY PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/07/2020
Last Update Date: 04/09/2024
Certification Date: 04/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

349 VENUS ST
MONROE NC
28112-4025
US

IV. Provider business mailing address

11301 GOLF LINKS DR N STE 203
CHARLOTTE NC
28277-8014
US

V. Phone/Fax

Practice location:
  • Phone: 980-380-9901
  • Fax: 704-541-6558
Mailing address:
  • Phone: 704-321-3376
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number001009701
License Number StateNC

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: