Provider Demographics
NPI:1730266453
Name:CUDD, MARY LEE (PAC)
Entity type:Individual
Prefix:MS
First Name:MARY
Middle Name:LEE
Last Name:CUDD
Suffix:
Gender:F
Credentials:PAC
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Mailing Address - Street 1:1774 METROMEDICAL DRIVE
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28304
Mailing Address - Country:US
Mailing Address - Phone:910-323-1203
Mailing Address - Fax:910-323-3101
Practice Address - Street 1:1774 METROMEDICAL DRIVE
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28304
Practice Address - Country:US
Practice Address - Phone:910-323-1203
Practice Address - Fax:910-323-3101
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2012-01-24
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NC0100900363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
Q63521Medicare UPIN
NC2765198Medicare ID - Type Unspecified