Provider Demographics
NPI:1477795821
Name:LAKE WACCAMAW PRIMARY CARE, PLLC
Entity Type:Organization
Organization Name:LAKE WACCAMAW PRIMARY CARE, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:AMY
Authorized Official - Middle Name:G
Authorized Official - Last Name:GAWEDA
Authorized Official - Suffix:
Authorized Official - Credentials:FNP
Authorized Official - Phone:910-646-6617
Mailing Address - Street 1:121 BRETONSHIRE RD
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28405-4001
Mailing Address - Country:US
Mailing Address - Phone:910-617-6202
Mailing Address - Fax:
Practice Address - Street 1:107 CHURCH ST
Practice Address - Street 2:
Practice Address - City:LAKE WACCAMAW
Practice Address - State:NC
Practice Address - Zip Code:28450-1908
Practice Address - Country:US
Practice Address - Phone:910-646-6617
Practice Address - Fax:910-646-6620
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-04-01
Last Update Date:2009-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC92226207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty