Healthcare Provider Details

I. General information

NPI: 1366650707
Provider Name (Legal Business Name): LAKESHORE PEDIATRIC CENTER, P.A.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/18/2007
Last Update Date: 02/04/2011
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

275 N HWY 16 SUITE: 103 LAKESHORE PEDIATRIC CENTER.
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

VIII. Authorized Official

Name: DR. WISSAM NADRA
Title or Position: PRESIDENT
Credential: MD
Phone: 704-489-8401