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General NPI Number Information
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NPI Number | 1093005878
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Entity Type | Organization
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Legal Business Name | LAKE NORMAN SURGICAL ASSISTING
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Dates
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Enumeration Date | 04/13/2011
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Last Update Date | 04/01/2014
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Provider Practice Location Address
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Address Line | 1130 GRACE MEADOW DR
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City | MOORESVILLE
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State | NC
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Zip | 28115-2789
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Country | US
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Telephone | 704-663-4989
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Fax |
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Provider Business Mailing Address
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Address Line | 1130 GRACE MEADOW DR
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City | MOORESVILLE
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State | NC
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Zip | 28115-2789
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Country | US
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Telephone | 704-663-4989
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Fax |
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Authorized Official
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Title or Position | MANAGING PARTNER
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Name | CHARLES ANTHONY TUDOR
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Credential | PA-C
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Telephone | 704-663-4989
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363AS0400X
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Taxonomy Name | Surgical Physician Assistant
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License Number | 101593
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License Number State | NC
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