Healthcare Provider Details

I. General information

NPI: 1497815328
Provider Name (Legal Business Name): WAKE DERMATOLOGY ASSOCIATES, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/11/2006
Last Update Date: 04/04/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4414 LAKE BOONE TRL STE 408
RALEIGH NC
27607-7513
US

IV. Provider business mailing address

4414 LAKE BOONE TRL STE 408
RALEIGH NC
27607-7513
US

V. Phone/Fax

Practice location:
  • Phone: 919-781-1001
  • Fax: 919-781-3909
Mailing address:
  • Phone: 919-781-1001
  • Fax: 919-781-3909

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number40537
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code207NS0135X
TaxonomyProcedural Dermatology Physician
License Number40537
License Number StateNC

VIII. Authorized Official

Name: DR. ADNAN NASIR
Title or Position: PHYSICIAN, OWNER
Credential: M.D.
Phone: 919-781-1001