Individual
ALBERT PETRUS WIRAWAN
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
RN, NP-C, MSN
Contact information
Practice address
200 HAWTHORNE LN, CHARLOTTE, NC 28204-2515
(704) 384-5416
(704) 384-5992
Mailing address
PO BOX 60447, CHARLOTTE, NC 28260-0447
(704) 384-5416
(704) 384-5992
Taxonomy
Speciality
Code
Description
License number
State
363L00000X
Nurse Practitioner
Primary
5005467
NC
363LF0000X
Family Nurse Practitioner
5005467
NC
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
1831461987
—
NC
Enumeration date
02/06/2012
Last updated
10/29/2020
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