Healthcare Provider Details

I. General information

NPI: 1083132773
Provider Name (Legal Business Name): GREGORY ATIKA ISABWA NP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/01/2017
Last Update Date: 04/01/2021
Certification Date: 04/01/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4420 LAKE BOONE TRL
RALEIGH NC
27607
US

IV. Provider business mailing address

116 SUNFLOWER WAY
CLAYTON NC
27527-9292
US

V. Phone/Fax

Practice location:
  • Phone: 919-784-7093
  • Fax: 919-784-7395
Mailing address:
  • Phone: 781-308-4106
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number5009842
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: