Healthcare Provider Details

I. General information

NPI: 1619973054
Provider Name (Legal Business Name): LAKESIDE DERMATOLOGY , PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/21/2005
Last Update Date: 03/23/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19900 W CATAWBA AVE SUITE B
CORNELIUS NC
28031-4032
US

IV. Provider business mailing address

19900 W CATAWBA AVE STE B
CORNELIUS NC
28031-4032
US

V. Phone/Fax

Practice location:
  • Phone: 704-892-4878
  • Fax: 704-892-7453
Mailing address:
  • Phone: 704-892-4878
  • Fax: 704-892-7453

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number9400198
License Number StateNC

VIII. Authorized Official

Name: NANCY J ASTLE
Title or Position: PRESIDENT/PHYSICIAN
Credential: MD
Phone: 704-892-4878