1184706806 NPI number — DALENA MAE CUSTER PA-C

Table of content: DALENA MAE CUSTER PA-C (NPI 1184706806)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1184706806 NPI number — DALENA MAE CUSTER PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CUSTER
Provider First Name:
DALENA
Provider Middle Name:
MAE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PA-C
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
WENNER
Provider Other First Name:
DALENA
Provider Other Middle Name:
MAE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
PA-C
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1184706806
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/18/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2240 REMOUNT RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GASTONIA
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28054-4725
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
704-671-5311
Provider Business Mailing Address Fax Number:
704-671-5308

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2711 X RAY DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GASTONIA
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28054-7491
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
704-834-2420
Provider Business Practice Location Address Fax Number:
704-834-2426
Provider Enumeration Date:
10/20/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363AM0700X , with the licence number:  001000302 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363A00000X , with the licence number: 0010-00302 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)