Healthcare Provider Details

I. General information

NPI: 1154518900
Provider Name (Legal Business Name): CAROL SUE CDEBACA PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/26/2007
Last Update Date: 04/23/2025
Certification Date: 04/23/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12901 BRIGGS RD
CHESTER VA
23831-5335
US

IV. Provider business mailing address

12901 BRIGGS RD
CHESTER VA
23831-5335
US

V. Phone/Fax

Practice location:
  • Phone: 804-715-4709
  • Fax: 804-715-4709
Mailing address:
  • Phone: 804-715-4709
  • Fax: 804-715-4714

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number0110002628
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: