Healthcare Provider Details

I. General information

NPI: 1659947117
Provider Name (Legal Business Name): CENTERS FOR ADVANCED UROLOGY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/03/2021
Last Update Date: 10/28/2025
Certification Date: 10/28/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1904 S MAIN ST STE 114
WAKE FOREST NC
27587-5030
US

IV. Provider business mailing address

1904 S MAIN ST STE 114
WAKE FOREST NC
27587-5030
US

V. Phone/Fax

Practice location:
  • Phone: 919-390-3978
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332900000X
TaxonomyNon-Pharmacy Dispensing Site
License Number
License Number State

VIII. Authorized Official

Name: JOANIE MARIE COCHRAN
Title or Position: CREDENTIALING AGENT
Credential:
Phone: 336-306-9755