Healthcare Provider Details

I. General information

NPI: 1023928256
Provider Name (Legal Business Name): KWANGSUN JOO SRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/10/2026
Last Update Date: 09/10/2026
Certification Date: 09/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

475 VINE ST
WINSTON SALEM NC
27101-4135
US

IV. Provider business mailing address

1440 BROOKWOOD DR
WINSTON SALEM NC
27106-4115
US

V. Phone/Fax

Practice location:
  • Phone: 857-998-7581
  • Fax:
Mailing address:
  • Phone: 857-998-7581
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WC0200X
TaxonomyCritical Care Medicine Registered Nurse
License Number1191455
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: