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NPI Code Detail

MEDICARE: MRS. DALENA MAE CUSTER PA-C

MEDICARE: MRS. DALENA MAE CUSTER PA-C
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1363A00000XPhysician Assistant0010-00302NC
2363AM0700XMedical Physician Assistant001000302NC

General Provider Information

NPI Number : 1184706806
Entity Type Code : Individual
Provider Name (Legal Business Name) : MRS. DALENA MAE CUSTER PA-C
Provider Business Mailing Address
First Line : 5960 FAIRVIEW RD STE 500
Second Line :
City : CHARLOTTE
State : NC
Zip : 28210-3113
Country : US
Telephone Number : 704-495-6334
Fax Number :
Provider Business Practice Location Address
First Line : 10635 PARK RD STE I
Second Line :
City : CHARLOTTE
State : NC
Zip : 28210-8408
Country : US
Telephone Number : 704-495-6334
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 10/20/2006
Last Update Date : 01/05/2026

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