Healthcare Provider Details

I. General information

NPI: 1790782126
Provider Name (Legal Business Name): WAKE FOREST PEDIATRIC ASSOCIATES, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/30/2005
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1655 WAKE DRIVE SUITE 101
WAKE FOREST NC
27587-7324
US

IV. Provider business mailing address

1655 WAKE DRIVE SUITE 101
WAKE FOREST NC
27587-7324
US

V. Phone/Fax

Practice location:
  • Phone: 919-556-1541
  • Fax: 919-556-5277
Mailing address:
  • Phone: 919-556-1541
  • Fax: 919-556-5277

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number StateNC

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier89012T6
Identifier TypeMEDICAID
Identifier StateNC
Identifier Issuer

VIII. Authorized Official

Name: NAOMI WEINSTEIN
Title or Position: MANAGER OF CORP
Credential:
Phone: 919-556-1541