Healthcare Provider Details

I. General information

NPI: 1740250463
Provider Name (Legal Business Name): MAYBELLE M MADLOCK P.A.-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/25/2006
Last Update Date: 05/19/2026
Certification Date: 05/19/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10931 RAVEN RIDGE RD STE 101
RALEIGH NC
27614-6499
US

IV. Provider business mailing address

PO BOX 23329
NEW YORK NY
10087-3329
US

V. Phone/Fax

Practice location:
  • Phone: 919-870-6600
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number001000379
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: