Provider Demographics
NPI:1841207719
Name:MUNDY, JONATHAN TODD (PAC)
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:TODD
Last Name:MUNDY
Suffix:
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1717
Mailing Address - Street 2:
Mailing Address - City:BURLINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:27216-1717
Mailing Address - Country:US
Mailing Address - Phone:336-538-1234
Mailing Address - Fax:336-538-2390
Practice Address - Street 1:1234 HUFFMAN MILL RD
Practice Address - Street 2:
Practice Address - City:BURLINGTON
Practice Address - State:NC
Practice Address - Zip Code:27215-8700
Practice Address - Country:US
Practice Address - Phone:336-538-1234
Practice Address - Fax:336-538-2390
Is Sole Proprietor?:No
Enumeration Date:2006-08-02
Last Update Date:2022-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC103035363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8101201Medicaid
NC8101201Medicaid
NC2752880Medicare ID - Type Unspecified