Provider Demographics
NPI:1154318350
Name:NADRA, WISSAM EDWARD (MD)
Entity Type:Individual
Prefix:
First Name:WISSAM
Middle Name:EDWARD
Last Name:NADRA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:LAKESHORE PEDIATRIC CENTER
Mailing Address - Street 2:P.O. BOX 1470
Mailing Address - City:DENVER
Mailing Address - State:NC
Mailing Address - Zip Code:28037
Mailing Address - Country:US
Mailing Address - Phone:704-489-8401
Mailing Address - Fax:704-489-8404
Practice Address - Street 1:275 N. HWY 16. SUITE: 103
Practice Address - Street 2:LAKESHORE PEDIATRIC CENTER
Practice Address - City:DENVER
Practice Address - State:NC
Practice Address - Zip Code:28037
Practice Address - Country:US
Practice Address - Phone:704-489-8401
Practice Address - Fax:704-489-8404
Is Sole Proprietor?:No
Enumeration Date:2005-10-03
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NC2000-00103208000000X
CAA67393208000000X
AZ27533208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC89126ERMedicaid
NC5950140Medicaid
NC5950140Medicaid
NCBN 6287014OtherDEA NUMBER