Healthcare Provider Details

I. General information

NPI: 1083490536
Provider Name (Legal Business Name): COASTAL CAROLINA HEALTH CARE, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/31/2023
Last Update Date: 11/10/2025
Certification Date: 11/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

900 MEDICAL PARK AVE
NEW BERN NC
28562
US

IV. Provider business mailing address

1020 MEDICAL PARK AVE
NEW BERN NC
28562-5248
US

V. Phone/Fax

Practice location:
  • Phone: 252-514-6685
  • Fax:
Mailing address:
  • Phone: 252-514-6685
  • Fax: 252-514-2745

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number
License Number State

VIII. Authorized Official

Name: STEPHEN NUCKOLLS
Title or Position: CEO
Credential:
Phone: 252-514-6685