1023068624 NPI number — MRS. CASSANDRA LYNN STULL MPAS, PA-C

Table of content: MRS. CASSANDRA LYNN STULL MPAS, PA-C (NPI 1023068624)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1023068624 NPI number — MRS. CASSANDRA LYNN STULL MPAS, PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
STULL
Provider First Name:
CASSANDRA
Provider Middle Name:
LYNN
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
MPAS, 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:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1023068624
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/03/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
MARY S SHOOK STUDENT HEALTH SERVICES
Provider Second Line Business Mailing Address:
614 HOWARD ST PO OFFICE BOX 32070
Provider Business Mailing Address City Name:
BOONE
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28608-2070
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
828-262-3100
Provider Business Mailing Address Fax Number:
828-262-6262

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
MARY S SHOOK STUDENT HEALTH SERVICES
Provider Second Line Business Practice Location Address:
614 HOWARD ST PO OFFICE BOX 32070
Provider Business Practice Location Address City Name:
BOONE
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28608-2070
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
828-262-3100
Provider Business Practice Location Address Fax Number:
828-262-6262
Provider Enumeration Date:
05/12/2006

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: 363A00000X , with the licence number:  001000297 , 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)

  • Identifier: 200205133 . This is a "UNITED HEALTHCARE" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 56142 . This is a "HEALTHCARE SYSTEMS" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 8989937 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0871437 . This is a "CIGNA" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 34D1018993 . This is a "CLIA WAVE" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 89937 . This is a "PROVIDER BCBS" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: D0263 . This is a "MEDCOST PROVIDER" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".




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