Provider Demographics
NPI:1669851416
Name:LAKE, NICHOLAS HELLER (MD)
Entity Type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:HELLER
Last Name:LAKE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4601 PARK RD STE 300
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28209-2290
Mailing Address - Country:US
Mailing Address - Phone:704-323-2505
Mailing Address - Fax:
Practice Address - Street 1:620 JOHN PAUL JONES CIR
Practice Address - Street 2:
Practice Address - City:PORTSMOUTH
Practice Address - State:VA
Practice Address - Zip Code:23708-2111
Practice Address - Country:US
Practice Address - Phone:858-525-2842
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-05-27
Last Update Date:2022-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171000000X
NC2020-02932207X00000X
NE29393207XS0106X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XS0106XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryHand Surgery
No171000000XOther Service ProvidersMilitary Health Care Provider
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC0397730007OtherNSC#