Provider Demographics
NPI:1740250463
Name:MADLOCK, MAYBELLE M (PA-C)
Entity type:Individual
Prefix:MRS
First Name:MAYBELLE
Middle Name:M
Last Name:MADLOCK
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Gender:F
Credentials:PA-C
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Mailing Address - Street 1:10931 RAVEN RIDGE RD
Mailing Address - Street 2:STE 101
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27614-6499
Mailing Address - Country:US
Mailing Address - Phone:919-870-6600
Mailing Address - Fax:919-870-1610
Practice Address - Street 1:101 SW CARY PKWY
Practice Address - Street 2:SUITE 210
Practice Address - City:CARY
Practice Address - State:NC
Practice Address - Zip Code:27511-5562
Practice Address - Country:US
Practice Address - Phone:919-467-8556
Practice Address - Fax:919-380-1480
Is Sole Proprietor?:No
Enumeration Date:2006-01-25
Last Update Date:2019-09-27
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Provider Licenses
StateLicense IDTaxonomies
NC001000379363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
P82195Medicare UPIN