Provider Demographics
NPI:1760483697
Name:FUQUA, MANDRIA L (PA-C)
Entity Type:Individual
Prefix:
First Name:MANDRIA
Middle Name:L
Last Name:FUQUA
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2137 LAKESIDE DR
Mailing Address - Street 2:SUITE 100
Mailing Address - City:LYNCHBURG
Mailing Address - State:VA
Mailing Address - Zip Code:24501-6806
Mailing Address - Country:US
Mailing Address - Phone:434-385-4184
Mailing Address - Fax:434-385-8616
Practice Address - Street 1:2137 LAKESIDE DR
Practice Address - Street 2:SUITE 100
Practice Address - City:LYNCHBURG
Practice Address - State:VA
Practice Address - Zip Code:24501-6806
Practice Address - Country:US
Practice Address - Phone:434-385-4184
Practice Address - Fax:434-385-8616
Is Sole Proprietor?:No
Enumeration Date:2005-08-02
Last Update Date:2013-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC104177363AM0700X
VA0110002029363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
2763053BMedicare PIN
NCQ37365Medicare UPIN
VV7137A - CVFPMedicare PIN
NC0480730001Medicare NSC
NC2763053Medicare ID - Type Unspecified