Healthcare Provider Details

I. General information

NPI: 1346852407
Provider Name (Legal Business Name): WAKE SPECIALTY PHYSICIANS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/20/2020
Last Update Date: 01/05/2022
Certification Date: 01/05/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2001 S MAIN ST STE 200
WAKE FOREST NC
27587-1652
US

IV. Provider business mailing address

2001 S MAIN ST STE 200
WAKE FOREST NC
27587-1652
US

V. Phone/Fax

Practice location:
  • Phone: 919-235-6540
  • Fax: 919-235-6504
Mailing address:
  • Phone: 919-235-6540
  • Fax: 919-235-6504

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: SHONDRA LYNN BRINK
Title or Position: VP OPERATIONS
Credential:
Phone: 919-350-6045