Provider Demographics
NPI:1811433345
Name:SURA, KAVITA
Entity type:Individual
Prefix:
First Name:KAVITA
Middle Name:
Last Name:SURA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:40 AUTUMN FERN TRL
Mailing Address - Street 2:
Mailing Address - City:LILLINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:27546-5155
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:40 AUTUMN FERN TRL
Practice Address - Street 2:
Practice Address - City:LILLINGTON
Practice Address - State:NC
Practice Address - Zip Code:27546-5155
Practice Address - Country:US
Practice Address - Phone:919-995-1436
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-08
Last Update Date:2017-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-06879363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant