Provider Demographics
NPI:1548765167
Name:SOLOMON, DEMISSIE H
Entity Type:Individual
Prefix:
First Name:DEMISSIE
Middle Name:H
Last Name:SOLOMON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:910 W HARRISON ST
Mailing Address - Street 2:
Mailing Address - City:REIDSVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27320-3324
Mailing Address - Country:US
Mailing Address - Phone:336-342-9564
Mailing Address - Fax:336-349-9723
Practice Address - Street 1:910 W HARRISON ST
Practice Address - Street 2:
Practice Address - City:REIDSVILLE
Practice Address - State:NC
Practice Address - Zip Code:27320-3324
Practice Address - Country:US
Practice Address - Phone:336-342-9564
Practice Address - Fax:336-349-9723
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-26
Last Update Date:2022-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVAPRN002862163WG0600X, 363LG0600X
NC5013570363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
No163WG0600XNursing Service ProvidersRegistered NurseGerontology
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NVAPRN002862OtherSTATE LICENSE
NV1548765167Medicaid
NCCNP5013570OtherSTATE LICENSE