Healthcare Provider Details

I. General information

NPI: 1043851801
Provider Name (Legal Business Name): CODY ADAM MYRICK PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/03/2019
Last Update Date: 07/19/2024
Certification Date: 07/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5093 UNIVERSITY PKWY
WINSTON SALEM NC
27106-6085
US

IV. Provider business mailing address

645 N MAIN ST
HIGH POINT NC
27260-5017
US

V. Phone/Fax

Practice location:
  • Phone: 336-883-0029
  • Fax:
Mailing address:
  • Phone: 336-883-0029
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208VP0000X
TaxonomyPain Medicine Physician
License Number0010-09573
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number0010-09573
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: