1518922905 NPI number — MR. WASSEEM JOHN WAHBA PA-C

Table of content: MR. WASSEEM JOHN WAHBA PA-C (NPI 1518922905)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1518922905 NPI number — MR. WASSEEM JOHN WAHBA PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WAHBA
Provider First Name:
WASSEEM
Provider Middle Name:
JOHN
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
PA-C
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
WAHBA
Provider Other First Name:
W JOHN
Provider Other Middle Name:
Provider Other Name Prefix Text:
MR.
Provider Other Name Suffix Text:
Provider Other Credential Text:
PA-C
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1518922905
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/16/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
127 E LAURENBROOK CT
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CARY
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
27518-6844
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
919-457-6960
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3000 NEW BERN AVE
Provider Second Line Business Practice Location Address:
WAKE EMERGENCY PHYSICIANS
Provider Business Practice Location Address City Name:
RALEIGH
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
27610-1231
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
919-350-8823
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/19/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363A00000X , with the licence number:  102441 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: AW1936 . This is a "HEALTHNET GRP #" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".
  • Identifier: 453051001 . This is a "GROUP HEALTH GRP #" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".
  • Identifier: 794744 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".
  • Identifier: 860373636 . This is a "HUMANA GROUP #" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".
  • Identifier: 3981220 . This is a "EVERCARE GROUP #" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".




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