Provider Demographics
NPI:1093005878
Name:LAKE NORMAN SURGICAL ASSISTING
Entity Type:Organization
Organization Name:LAKE NORMAN SURGICAL ASSISTING
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:ANTHONY
Authorized Official - Last Name:TUDOR
Authorized Official - Suffix:
Authorized Official - Credentials:PA-C
Authorized Official - Phone:704-663-4989
Mailing Address - Street 1:1130 GRACE MEADOW DR
Mailing Address - Street 2:
Mailing Address - City:MOORESVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28115-2789
Mailing Address - Country:US
Mailing Address - Phone:704-663-4989
Mailing Address - Fax:
Practice Address - Street 1:1130 GRACE MEADOW DR
Practice Address - Street 2:
Practice Address - City:MOORESVILLE
Practice Address - State:NC
Practice Address - Zip Code:28115-2789
Practice Address - Country:US
Practice Address - Phone:704-663-4989
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-04-13
Last Update Date:2014-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC101593363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
2348238OtherMEDICARE GROUP PTAN