Provider Demographics
NPI:1598572588
Name:SUDDERTH, GILLIAN (PA-C)
Entity type:Individual
Prefix:
First Name:GILLIAN
Middle Name:
Last Name:SUDDERTH
Suffix:
Gender:F
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 1:11009 INGLESIDE PL STE 201
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27614-6697
Mailing Address - Country:US
Mailing Address - Phone:919-844-3244
Mailing Address - Fax:
Practice Address - Street 1:11009 INGLESIDE PL STE 201
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27614-6697
Practice Address - Country:US
Practice Address - Phone:919-844-4344
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-12-13
Last Update Date:2024-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC001014585363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant