Individual
PHAT V LE
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
AA
Contact information
Practice address
3400 WAKE FOREST RD, RALEIGH, NC 27609-7317
(919) 954-3000
Mailing address
3100 SPRING FOREST RD STE 130, RALEIGH, NC 27616-2880
(919) 873-9533
(844) 454-0171
Taxonomy
Speciality
Code
Description
License number
State
367H00000X
Anesthesiologist Assistant
Primary
2012028965
MO
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
1437408531
—
MO
01
—
431560263
TRICARE
MO
01
—
P01129107
RR MCR
MO
Enumeration date
09/05/2012
Last updated
03/17/2018
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