Basic Information
| Provider Information | |||||||||
| NPI: | 1154672426 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SURENDRA | ||||||||
| FirstName: | CHRISTOPHER | ||||||||
| MiddleName: | MICHAEL | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1120 SE CARY PKWY | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | CARY | ||||||||
| State: | NC | ||||||||
| PostalCode: | 275187413 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9194674992 | ||||||||
| FaxNumber: | 9192325328 | ||||||||
| Practice Location | |||||||||
| Address1: | 1110 SE CARY PKWY | ||||||||
| Address2: | SUITE 103 | ||||||||
| City: | CARY | ||||||||
| State: | NC | ||||||||
| PostalCode: | 275187420 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9194674992 | ||||||||
| FaxNumber: | 9192325328 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/27/2012 | ||||||||
| LastUpdateDate: | 06/26/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/26/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 9763 | GA | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363AM0700X | C04849 | MD | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
ID Information
| ID | Type | State | Issuer | Description | MD061 | 01 | FL | FL MEDICARE | OTHER |