Healthcare Provider Details

I. General information

NPI: 1588366850
Provider Name (Legal Business Name): CAMRON KEON EDRISSI MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/20/2023
Last Update Date: 07/01/2026
Certification Date: 07/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

120 APPLECROSS RD
PINEHURST NC
28374-8520
US

IV. Provider business mailing address

120 APPLECROSS RD
PINEHURST NC
28374-8520
US

V. Phone/Fax

Practice location:
  • Phone: 910-692-8224
  • Fax:
Mailing address:
  • Phone: 910-692-8224
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number2025-04006
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: