=====================================================
General NPI Number Information
=====================================================
NPI Number | 1154318350
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | WISSAM EDWARD NADRA M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/03/2005
-----------------------------------------------------
Last Update Date | 03/07/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 275 N. HWY 16. SUITE: 103 LAKESHORE PEDIATRIC CENTER
-----------------------------------------------------
City | DENVER
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28037
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 704-489-8401
-----------------------------------------------------
Fax | 704-489-8404
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | LAKESHORE PEDIATRIC CENTER P.O. BOX 1470
-----------------------------------------------------
City | DENVER
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28037
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 704-489-8401
-----------------------------------------------------
Fax | 704-489-8404
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208000000X
-----------------------------------------------------
Taxonomy Name | Pediatrics Physician
-----------------------------------------------------
License Number | 2000-00103
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 208000000X
-----------------------------------------------------
Taxonomy Name | Pediatrics Physician
-----------------------------------------------------
License Number | A67393
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 208000000X
-----------------------------------------------------
Taxonomy Name | Pediatrics Physician
-----------------------------------------------------
License Number | 27533
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------