Provider Demographics
NPI:1851368351
Name:RADFORD, WANDA LEE
Entity Type:Individual
Prefix:
First Name:WANDA
Middle Name:LEE
Last Name:RADFORD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3100 BLUE RIDGE ROAD
Mailing Address - Street 2:300
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27607
Mailing Address - Country:US
Mailing Address - Phone:919-781-7500
Mailing Address - Fax:919-645-3440
Practice Address - Street 1:3100 BLUE RIDGE ROAD
Practice Address - Street 2:300
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27607
Practice Address - Country:US
Practice Address - Phone:919-781-7500
Practice Address - Fax:919-645-3440
Is Sole Proprietor?:No
Enumeration Date:2006-03-02
Last Update Date:2012-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC20184207VG0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC154780OtherWELLPATH
NC89699Medicaid
NC29643OtherMEDCOST
NC69919OtherBCBS
NC4481969OtherAETNA
NC562142486OtherUHC
NC1548820004OtherCIGNA
NC562142486OtherUHC
NC29643OtherMEDCOST