Provider Demographics
NPI:1497815328
Name:WAKE DERMATOLOGY ASSOCIATES, PA
Entity Type:Organization
Organization Name:WAKE DERMATOLOGY ASSOCIATES, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN, OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ADNAN
Authorized Official - Middle Name:
Authorized Official - Last Name:NASIR
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:919-781-1001
Mailing Address - Street 1:4414 LAKE BOONE TRL
Mailing Address - Street 2:STE 408
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27607-7513
Mailing Address - Country:US
Mailing Address - Phone:919-781-1001
Mailing Address - Fax:919-781-3909
Practice Address - Street 1:4414 LAKE BOONE TRL
Practice Address - Street 2:STE 408
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27607-7513
Practice Address - Country:US
Practice Address - Phone:919-781-1001
Practice Address - Fax:919-781-3909
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-11
Last Update Date:2011-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC40537207N00000X, 207NS0135X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
No207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural DermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
2344640OtherMEDICARE GROUP NUMBER
NC02261OtherBLUE CROSS GROUP NUMBER
2264790Medicare PIN
2029252Medicare PIN