Healthcare Provider Details

I. General information

NPI: 1881384485
Provider Name (Legal Business Name): RYAN CHRISTOPHER WOLBACH FNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/09/2023
Last Update Date: 05/17/2024
Certification Date: 05/17/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4431 US HIGHWAY 220 N
SUMMERFIELD NC
27358-9411
US

IV. Provider business mailing address

100 KIMEL FOREST DR
WINSTON SALEM NC
27103-6074
US

V. Phone/Fax

Practice location:
  • Phone: 336-643-7711
  • Fax: 336-643-3047
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPN27286
License Number StateSC
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number5019898
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: