Healthcare Provider Details

I. General information

NPI: 1609087881
Provider Name (Legal Business Name): PANIDA PIBOOLNURAK MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/27/2007
Last Update Date: 05/26/2021
Certification Date: 05/26/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1509 DOCTORS CIR BLDG C
WILMINGTON NC
28401-7403
US

IV. Provider business mailing address

PO BOX 936857
ATLANTA GA
31193-6857
US

V. Phone/Fax

Practice location:
  • Phone: 910-662-7500
  • Fax:
Mailing address:
  • Phone: 910-662-7500
  • Fax: 910-662-7501

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207T00000X
TaxonomyNeurological Surgery Physician
License Number2016-01975
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number51348
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: