Provider Demographics
NPI:1750021325
Name:HOMETOWN MED OF MOYOCK AND OBX PLLC
Entity Type:Organization
Organization Name:HOMETOWN MED OF MOYOCK AND OBX PLLC
Other - Org Name:HOMETOWN MED OF MOYOCK AND OBX PLLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CARMEN
Authorized Official - Middle Name:M
Authorized Official - Last Name:WYNES
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:252-772-1110
Mailing Address - Street 1:109 CURRITUCK COMMERICAL DR STE A
Mailing Address - Street 2:
Mailing Address - City:MOYOCK
Mailing Address - State:NC
Mailing Address - Zip Code:27958-9068
Mailing Address - Country:US
Mailing Address - Phone:252-772-1110
Mailing Address - Fax:252-319-3678
Practice Address - Street 1:109 CURRITUCK COMMERICAL DR STE A
Practice Address - Street 2:
Practice Address - City:MOYOCK
Practice Address - State:NC
Practice Address - Zip Code:27958-9068
Practice Address - Country:US
Practice Address - Phone:252-772-1110
Practice Address - Fax:252-319-3678
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-03-31
Last Update Date:2023-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary CareGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
No2083A0300XAllopathic & Osteopathic PhysiciansPreventive MedicineAddiction MedicineGroup - Single Specialty
No261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary CareGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1073000816Medicaid
NC1750021325Medicaid