Provider Demographics
NPI:1922080811
Name:SUTTON-SURAK, AUDREY LYNN (DO)
Entity Type:Individual
Prefix:DR
First Name:AUDREY
Middle Name:LYNN
Last Name:SUTTON-SURAK
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:1013 PORTERS NECK RD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28411-8130
Mailing Address - Country:US
Mailing Address - Phone:910-686-1099
Mailing Address - Fax:910-686-4715
Practice Address - Street 1:1013 PORTERS NECK RD
Practice Address - Street 2:SUITE 100
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28411
Practice Address - Country:US
Practice Address - Phone:910-686-1099
Practice Address - Fax:910-686-4715
Is Sole Proprietor?:No
Enumeration Date:2005-11-16
Last Update Date:2018-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MB6325500207Q00000X
NC200501955207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
1378260OtherUNITED HEATHCARE
5231159OtherAETNA
NC5904062Medicaid
9614555OtherCIGNA
9614555OtherCIGNA
670941OtherEMPIRE BCBS OF NY
080103630OtherRAILROAD MEDICARE
P379230OtherOXFORD HEALTH PLANS NJ
670493OtherEMPIRE BCBS OF NY
NJ7117809Medicaid
961670OtherAETNA HMO
0K4745OtherHEALTH NET OF NJ
P379230OtherOXFORD HEALTH PLANS NJ