Healthcare Provider Details

I. General information

NPI: 1538120910
Provider Name (Legal Business Name): DEPT OF VETERANS AFFAIRS OUTPATIENT CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/28/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

190 KIMEL PARK DR
WINSTON-SALEM NC
27103-6946
US

IV. Provider business mailing address

190 KIMEL PARK DR
WINSTON-SALEM NC
27103-6946
US

V. Phone/Fax

Practice location:
  • Phone: 336-768-7696
  • Fax:
Mailing address:
  • Phone: 336-768-7696
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number600091
License Number StateNC

VIII. Authorized Official

Name: DR. STEPHRN BUETTLE
Title or Position: CHIEF OF STAFF
Credential: MD
Phone: 336-768-3296