Provider Demographics
NPI:1184706806
Name:CUSTER, DALENA MAE (PA-C)
Entity type:Individual
Prefix:
First Name:DALENA
Middle Name:MAE
Last Name:CUSTER
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:DALENA
Other - Middle Name:MAE
Other - Last Name:WENNER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:2240 REMOUNT RD
Mailing Address - Street 2:
Mailing Address - City:GASTONIA
Mailing Address - State:NC
Mailing Address - Zip Code:28054-4725
Mailing Address - Country:US
Mailing Address - Phone:704-671-5311
Mailing Address - Fax:704-671-5308
Practice Address - Street 1:2711 X RAY DR
Practice Address - Street 2:
Practice Address - City:GASTONIA
Practice Address - State:NC
Practice Address - Zip Code:28054-7491
Practice Address - Country:US
Practice Address - Phone:704-834-2420
Practice Address - Fax:704-834-2426
Is Sole Proprietor?:No
Enumeration Date:2006-10-20
Last Update Date:2010-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC001000302363AM0700X
NC0010-00302363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC2768434Medicare PIN