1497166334 NPI number — WAKE SPECIALTY PHYSICIANS, LLC

Table of content: ARNEDA FAYE LYONS FNP (NPI 1033119078)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1497166334 NPI number — WAKE SPECIALTY PHYSICIANS, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WAKE SPECIALTY PHYSICIANS, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
WAKEMED UROLOGY
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1497166334
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/12/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 602195
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHARLOTTE
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28260-2195
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
919-350-0554
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3024 NEW BERN AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
RALEIGH
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
27610-1247
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
919-350-7251
Provider Business Practice Location Address Fax Number:
919-350-1606
Provider Enumeration Date:
05/14/2014

Additional Information

Authorized Official

Authorized Official Last Name:
JAYOUSSI
Authorized Official First Name:
MARIA
Authorized Official Middle Name:
Authorized Official Title or Position:
EXECUTIVE DIRECTOR
Authorized Official Telephone Number:
919-350-6089

Provider Taxonomy Codes

  • Taxonomy code: 208800000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1942440375 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".




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