Healthcare Provider Details

I. General information

NPI: 1043661432
Provider Name (Legal Business Name): COLE C PODRAZA PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/27/2016
Last Update Date: 11/21/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4515 PREMIER DR STE 204
HIGH POINT NC
27265
US

IV. Provider business mailing address

100 KIMEL FOREST DR
WINSTON SALEM NC
27103-6074
US

V. Phone/Fax

Practice location:
  • Phone: 336-802-2075
  • Fax: 336-802-2076
Mailing address:
  • Phone: 336-716-1331
  • Fax: 336-716-3202

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number0010-06545
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: