Healthcare Provider Details

I. General information

NPI: 1174022743
Provider Name (Legal Business Name): ANDREW RONALD BRAKE FNP-BC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/08/2018
Last Update Date: 11/13/2024
Certification Date: 11/13/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1210 NEW GARDEN RD
GREENSBORO NC
27410
US

IV. Provider business mailing address

3305 FARM LAKE ST
JAMESTOWN NC
27282-7514
US

V. Phone/Fax

Practice location:
  • Phone: 336-294-6190
  • Fax: 336-294-6278
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WM0705X
TaxonomyMedical-Surgical Registered Nurse
License Number269582
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number269582
License Number StateNC
# 3
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number269582
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: