Provider Demographics
NPI:1619182383
Name:SOUTHERLAND, LUVAE (PA)
Entity Type:Individual
Prefix:
First Name:LUVAE
Middle Name:
Last Name:SOUTHERLAND
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4111 WENDELL BLVD
Mailing Address - Street 2:
Mailing Address - City:WENDELL
Mailing Address - State:NC
Mailing Address - Zip Code:27591-6831
Mailing Address - Country:US
Mailing Address - Phone:919-773-8888
Mailing Address - Fax:
Practice Address - Street 1:4111 WENDELL BLVD
Practice Address - Street 2:
Practice Address - City:WENDELL
Practice Address - State:NC
Practice Address - Zip Code:27591-6831
Practice Address - Country:US
Practice Address - Phone:919-250-1106
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-14
Last Update Date:2017-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC103366363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCP85386Medicare UPIN