Provider Demographics
NPI:1972004927
Name:SMALL, MAGGIE L (PA-C)
Entity Type:Individual
Prefix:
First Name:MAGGIE
Middle Name:L
Last Name:SMALL
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:MAGGIE
Other - Middle Name:L
Other - Last Name:BRADFORD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:3001 EDWARDS MILL RD STE 200
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27612-5243
Mailing Address - Country:US
Mailing Address - Phone:919-781-5600
Mailing Address - Fax:919-863-6821
Practice Address - Street 1:3001 EDWARDS MILL RD STE 200
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27612-5243
Practice Address - Country:US
Practice Address - Phone:919-781-5600
Practice Address - Fax:919-863-6821
Is Sole Proprietor?:No
Enumeration Date:2018-02-26
Last Update Date:2022-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-07932363A00000X
NC001007932363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant