Provider Demographics
NPI:1154518900
Name:CDEBACA, CAROL SUE (PA-C)
Entity type:Individual
Prefix:MS
First Name:CAROL
Middle Name:SUE
Last Name:CDEBACA
Suffix:
Gender:
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12901 BRIGGS RD
Mailing Address - Street 2:
Mailing Address - City:CHESTER
Mailing Address - State:VA
Mailing Address - Zip Code:23831-5335
Mailing Address - Country:US
Mailing Address - Phone:804-715-4709
Mailing Address - Fax:804-715-4714
Practice Address - Street 1:12901 BRIGGS RD
Practice Address - Street 2:
Practice Address - City:CHESTER
Practice Address - State:VA
Practice Address - Zip Code:23831-5335
Practice Address - Country:US
Practice Address - Phone:804-715-4709
Practice Address - Fax:804-715-4709
Is Sole Proprietor?:No
Enumeration Date:2007-09-26
Last Update Date:2025-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110002628363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1154518900OtherSOUTHERN HEALTH/CARENET/CARELINK/COVENTRY
VAP01464014OtherRAILROAD MEDICARE
VA1154518900OtherHUMANA MEDICARE
VA540506332115OtherTRICARE
VA1154518900OtherIN TOTAL
VA1154518900OtherOPTIMA HEALTH PLAN
VA1154518900OtherAETNA
VA1154518900OtherCCC VIRGINIA PREMIER
VA1154518900OtherMEDICAID QMB
VA1154518900OtherANTHEM MEDIGAP
VA1154518900OtherSOUTHERN HEALTH/CARENET/CARELINK/COVENTRY