Healthcare Provider Details

I. General information

NPI: 1154318350
Provider Name (Legal Business Name): WISSAM EDWARD NADRA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/03/2005
Last Update Date: 03/07/2023
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

275 N. HWY 16. SUITE: 103 LAKESHORE PEDIATRIC CENTER
DENVER NC
28037
US

IV. Provider business mailing address

LAKESHORE PEDIATRIC CENTER P.O. BOX 1470
DENVER NC
28037
US

V. Phone/Fax

Practice location:
  • Phone: 704-489-8401
  • Fax: 704-489-8404
Mailing address:
  • Phone: 704-489-8401
  • Fax: 704-489-8404

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number2000-00103
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA67393
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number27533
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: