Provider Demographics
NPI:1518156181
Name:LY, NICK MINH (DO)
Entity Type:Individual
Prefix:DR
First Name:NICK
Middle Name:MINH
Last Name:LY
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5079 SILAS CREEK RD
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27103-5961
Mailing Address - Country:US
Mailing Address - Phone:714-797-4080
Mailing Address - Fax:
Practice Address - Street 1:5079 SILAS CREEK RD
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27103-5961
Practice Address - Country:US
Practice Address - Phone:714-797-4080
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-10-19
Last Update Date:2020-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2013-02015207P00000X, 207Q00000X
CA20A10157208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine