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General NPI Number Information
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NPI Number | 1295255255
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Entity Type | Organization
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Legal Business Name | BLUE WATER EAR NOSE AND THROAT, P.A.
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Dates
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Enumeration Date | 06/21/2017
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Last Update Date | 07/21/2022
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Provider Practice Location Address
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Address Line | 4917 S CROATAN HWY STE 1C
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City | NAGS HEAD
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State | NC
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Zip | 27959-8996
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Country | US
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Telephone | 252-489-4682
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Fax |
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Provider Business Mailing Address
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Address Line | 4917 S CROATAN HWY STE 1C
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City | NAGS HEAD
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State | NC
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Zip | 27959-8996
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Country | US
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Telephone | 252-489-4682
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Fax |
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Authorized Official
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Title or Position | PHYSICIAN
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Name | DR. MARCI ELLEN LAIT
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Credential | MD
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Telephone | 252-489-4682
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Y00000X
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Taxonomy Name | Otolaryngology Physician
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License Number |
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License Number State | NC
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