Basic Information
| Provider Information | |||||||||
| NPI: | 1841207719 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MUNDY | ||||||||
| FirstName: | JONATHAN | ||||||||
| MiddleName: | TODD | ||||||||
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| Credential: | P.A.C. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1717 | ||||||||
| Address2: | |||||||||
| City: | BURLINGTON | ||||||||
| State: | NC | ||||||||
| PostalCode: | 272161717 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3365381234 | ||||||||
| FaxNumber: | 3365382390 | ||||||||
| Practice Location | |||||||||
| Address1: | 1234 HUFFMAN MILL RD | ||||||||
| Address2: | |||||||||
| City: | BURLINGTON | ||||||||
| State: | NC | ||||||||
| PostalCode: | 272158700 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3365381234 | ||||||||
| FaxNumber: | 3365382390 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/02/2006 | ||||||||
| LastUpdateDate: | 09/26/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/26/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AS0400X | 103035 | NC | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical |
ID Information
| ID | Type | State | Issuer | Description | 8101201 | 05 | NC | MEDICAID |