Organization
LAKE NORMAN SURGICAL ASSISTING
Active
Organization subpart
No
Provider details
NPI number
Authorized official
CHARLES ANTHONY TUDOR PA-C (MANAGING PARTNER)
(704) 663-4989
Entity
Organization
Contact information
Practice address
1130 GRACE MEADOW DR, MOORESVILLE, NC 28115-2789
(704) 663-4989
Mailing address
1130 GRACE MEADOW DR, MOORESVILLE, NC 28115-2789
(704) 663-4989
Taxonomy
Speciality
Code
Description
License number
State
363AS0400X
Surgical Physician Assistant
Primary
101593
NC
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
2348238
MEDICARE GROUP PTAN
—
Enumeration date
04/13/2011
Last updated
04/01/2014
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