Healthcare Provider Details

I. General information

NPI: 1477526861
Provider Name (Legal Business Name): NORTHWEST MEDICAL PARTNERS, P.A.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/08/2006
Last Update Date: 02/10/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

280 NORTH POINTE BLVD.
MT. AIRY NC
27030-2267
US

IV. Provider business mailing address

280 NORTH POINTE BLVD.
MT. AIRY NC
27030-2267
US

V. Phone/Fax

Practice location:
  • Phone: 336-786-4133
  • Fax: 336-786-4338
Mailing address:
  • Phone: 336-786-4133
  • Fax: 336-786-4338

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberL000989
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number30025
License Number StateNC

VIII. Authorized Official

Name: DONALD N. GARDNER
Title or Position: PRESIDENT
Credential: M.D.
Phone: 336-786-4133