Individual
GINA LOUISE MICCHIA
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
DO
Contact information
Practice address
10500 LIGON MILL RD, SUITE 113, WAKE FOREST, NC 27587-6090
(919) 570-5705
(919) 570-5710
Mailing address
PO BOX 60447, CHARLOTTE, NC 28260-0447
(704) 384-7840
(704) 384-7830
Taxonomy
Speciality
Code
Description
License number
State
174400000X
Specialist
OS008792L
PA
207Q00000X
Family Medicine Physician
Primary
2005-01657
NC
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
011630820
—
PA
01
—
142W6
BCBS
NC
05
—
5905076
—
NC
Enumeration date
02/16/2006
Last updated
04/18/2022
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