Provider Demographics
NPI:1821712175
Name:BLACK, HENRY CAMPBELL MCNAUGHTON
Entity Type:Individual
Prefix:
First Name:HENRY
Middle Name:CAMPBELL MCNAUGHTON
Last Name:BLACK
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 1:3031 NEW BERN AVE STE 306
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27610-2989
Mailing Address - Country:US
Mailing Address - Phone:919-876-7807
Mailing Address - Fax:
Practice Address - Street 1:3031 NEW BERN AVE STE 306
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27610-2989
Practice Address - Country:US
Practice Address - Phone:919-876-7807
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-30
Last Update Date:2023-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-12600363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant