Healthcare Provider Details

I. General information

NPI: 1477795821
Provider Name (Legal Business Name): LAKE WACCAMAW PRIMARY CARE, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/01/2009
Last Update Date: 04/01/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

107 CHURCH ST
LAKE WACCAMAW NC
28450-1908
US

IV. Provider business mailing address

121 BRETONSHIRE RD
WILMINGTON NC
28405-4001
US

V. Phone/Fax

Practice location:
  • Phone: 910-646-6617
  • Fax: 910-646-6620
Mailing address:
  • Phone: 910-617-6202
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number92226
License Number StateNC

VIII. Authorized Official

Name: AMY G GAWEDA
Title or Position: PRESIDENT
Credential: FNP
Phone: 910-646-6617