Provider Demographics
NPI:1831461987
Name:WIRAWAN, ALBERT PETRUS (RN, NP-C, MSN)
Entity Type:Individual
Prefix:
First Name:ALBERT
Middle Name:PETRUS
Last Name:WIRAWAN
Suffix:
Gender:M
Credentials:RN, NP-C, MSN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 60447
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-0447
Mailing Address - Country:US
Mailing Address - Phone:704-384-5416
Mailing Address - Fax:704-384-5992
Practice Address - Street 1:200 HAWTHORNE LN
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28204-2515
Practice Address - Country:US
Practice Address - Phone:704-384-5416
Practice Address - Fax:704-384-5992
Is Sole Proprietor?:No
Enumeration Date:2012-02-06
Last Update Date:2020-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5005467363LF0000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1831461987Medicaid
NCNC5438AMedicare UPIN
NC1831461987Medicaid