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General NPI Number Information
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NPI Number | 1710434691
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Entity Type | Organization
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Legal Business Name | WAKE SPECIALTY PHYSICIANS LLC
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Dates
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Enumeration Date | 09/08/2016
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Last Update Date | 06/16/2018
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Provider Practice Location Address
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Address Line | 23 SUNNYBROOK RD
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City | RALEIGH
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State | NC
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Zip | 27610-1855
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Country | US
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Telephone | 919-350-6439
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Fax | 919-231-0314
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Provider Business Mailing Address
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Address Line | PO BOX 602195
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City | CHARLOTTE
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State | NC
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Zip | 28260-2195
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Country | US
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Telephone | 919-350-0554
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Fax |
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Authorized Official
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Title or Position | EXECUTIVE DIRECTOR, FINANCE
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Name | MARIA JAYOUSSI
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Credential |
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Telephone | 919-350-6089
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208000000X
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Taxonomy Name | Pediatrics Physician
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License Number |
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License Number State | NC
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Taxonomy #2
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Taxonomy Code | 2080B0002X
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Taxonomy Name | Pediatric Obesity Medicine Physician
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License Number |
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License Number State | NC
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