NPIMap

Individual provider Active NPI

Mallory Deanne Fairweather, PA-C

  • Medical Physician Assistant
  • Fayetteville, NC
National Provider Identifier
1770224438
Registry record updated Aug 11, 2025
On this page

Key facts

NPPES NPI Registry
Primary specialty
Medical Physician AssistantTaxonomy code 363AM0700X
Practice address
1638 Owen Dr
Fayetteville, NC 28304-3424
Phone
(910) 615-4000
NPI assigned
Apr 6, 2022
Last updated
Aug 11, 2025By the provider in NPPES
Sex
Female
Sole proprietor
No

NPPES NPI Registry

Updated by the provider on Aug 11, 2025

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
Medical Physician Assistant 363AM0700X NC Primary
Student in an Organized Health Care Education/Training Program 390200000X NU

Addresses

Primary practice location

1638 Owen Dr
Fayetteville, NC 28304-3424

Mailing address

8612 Malahar LN
Angier, NC 27501-5914
Phone (919) 906-2370

Other practice location 1

4350 US 421 S
Lillington, NC 27546-6760
Phone (910) 893-1210

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in NC
Eligible to order & refer
  • Part B services
  • Medical equipment
  • Home health
  • Power mobility devices
  • Hospice
Green means eligible to order or refer.

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
I20230720002805 NC Practitioner - Physician Assistant 0648630715 Reassigns benefits to 2 organizations

Care Compare profile

Medicare Care Compare
Specialty
Physician Assistant
Education
Other, 2022
Medicare assignment
Accepts the Medicare-approved amount as payment in full
Group practices
Id Care(R) - Infectious Diseases Specialty Practice PAGroup PAC ID 0345529988, 10 clinicians

Practice addresses (Care Compare)

1319 Avon St
Fayetteville, NC 28304-4423
Phone (910) 729-6552

1638 Owen Dr
Fayetteville, NC 28304-3424
Phone (910) 615-4000

Hospital & facility affiliations

National Provider Directory

National Provider Directory
Medicare enrollment (NPD)
Enrolled
Credentials
Physician Assistant

Practice roles

OrganizationSpecialtyStatusNew patients
Cumberland County Hospital System Inc CurrentSince Jun 6, 2023 Accepting new patients
Cumberland County Hospital System Inc CurrentSince Jun 6, 2023 Accepting new patients

Locations

1638 Owen Dr
Fayetteville, NC 28304
Phone (910) 609-5610

Interoperability endpoints

  • Direct secure messaging: jlym106745@capefearvalley.direct-ci.com

Organizations & group practices 4

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships, National Provider Directory roles and organizations whose NPPES authorized official is this provider.

Hospital & facility affiliations 14

Hospitals and other facilities this clinician is affiliated with according to Medicare Care Compare.

View all 14

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1649203200000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1754870400000",
    "number": "1770224438",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "8612 MALAHAR LN",
            "city": "ANGIER",
            "state": "NC",
            "postal_code": "275015914",
            "telephone_number": "919-906-2370"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1638 OWEN DR",
            "city": "FAYETTEVILLE",
            "state": "NC",
            "postal_code": "283043424",
            "telephone_number": "910-615-4000"
        }
    ],
    "practiceLocations": [
        {
            "address_1": "4350 US 421 S",
            "address_purpose": "LOCATION",
            "city": "Lillington",
            "state": "NC",
            "postal_code": "275466760",
            "country_code": "US",
            "telephone_number": "910-893-1210",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "basic": {
        "last_name": "FAIRWEATHER",
        "first_name": "MALLORY",
        "middle_name": "DEANNE",
        "name_prefix": "Ms.",
        "credential": "PA-C",
        "sole_proprietor": "NO",
        "sex": "F",
        "enumeration_date": "2022-04-06",
        "last_updated": "2025-08-11",
        "certification_date": "2025-08-11",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "363AM0700X",
            "taxonomy_group": "",
            "desc": "Physician Assistant, Medical",
            "state": "NC",
            "license": null,
            "primary": true
        },
        {
            "code": "390200000X",
            "taxonomy_group": "",
            "desc": "Student in an Organized Health Care Education/Training Program",
            "state": "NU",
            "license": null,
            "primary": false
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Fayetteville, NC

Sources for this page

Verify at the official NPI Registry.