Individual
EDGAR E NULL
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
FNP-C
Contact information
Practice address
606 W WEST ST, SOUTHPORT, NC 28461-3850
(540) 486-6600
Mailing address
606 W WEST ST, SOUTHPORT, NC 28461-3850
(540) 486-6600
Taxonomy
Speciality
Code
Description
License number
State
363LF0000X
Family Nurse Practitioner
Primary
F05240539
NC
Other
Enumeration date
06/01/2024
Last updated
06/01/2024
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