Provider Demographics
NPI: | 1356507446 |
---|---|
Name: | MOUSSA, MAHAMAN LAOUALI (NP) |
Entity Type: | Individual |
Prefix: | |
First Name: | MAHAMAN |
Middle Name: | LAOUALI |
Last Name: | MOUSSA |
Suffix: | |
Gender: | M |
Credentials: | NP |
Other - Prefix: | |
Other - First Name: | |
Other - Middle Name: | |
Other - Last Name: | |
Other - Suffix: | |
Other - Last Name Type: | |
Other - Credentials: | |
Mailing Address - Street 1: | 4692 BROWNSBORO ROAD |
Mailing Address - Street 2: | |
Mailing Address - City: | WINSTON - SALEM |
Mailing Address - State: | NC |
Mailing Address - Zip Code: | 27106 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 336-251-1114 |
Mailing Address - Fax: | 336-251-1116 |
Practice Address - Street 1: | 4692 BROWNSBORO ROAD |
Practice Address - Street 2: | |
Practice Address - City: | WINSTON - SALEM |
Practice Address - State: | NC |
Practice Address - Zip Code: | 27106 |
Practice Address - Country: | US |
Practice Address - Phone: | 336-251-1114 |
Practice Address - Fax: | 336-251-1116 |
Is Sole Proprietor?: | No |
Enumeration Date: | 2008-07-29 |
Last Update Date: | 2009-01-29 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
NC | 200356 | 363LF0000X |
NC | 5004034 | 363L00000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 363L00000X | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | |
No | 363LF0000X | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
NC | 2593362A | Other | MEDICARE |