WAKE NEPHROLOGY ASSOCIATES, P.A.

Provider Demographics

• NPI: 1891797049
• Name: WAKE NEPHROLOGY ASSOCIATES, P.A.
• Entity Type: Organization
• Organization Name: WAKE NEPHROLOGY ASSOCIATES, P.A.
• Authorized Official - Title/Position: PRACTICE MANAGER
• Authorized Official - Prefix: MRS
• Authorized Official - First Name: JAMIE
• Authorized Official - Middle Name: KENDRA
• Authorized Official - Last Name: FRICKE
• Authorized Official - Phone: 919-876-7807
• Mailing Address - Street 1: 3604 BUSH ST
• Mailing Address - City: RALEIGH
• Mailing Address - State: NC
• Mailing Address - Zip Code: 27609-7511
• Mailing Address - Country: US
• Mailing Address - Phone: 919-876-7807
• Mailing Address - Fax: 919-876-8823
• Practice Address - Street 1: 3604 BUSH ST
• Practice Address - City: RALEIGH
• Practice Address - State: NC
• Practice Address - Zip Code: 27609-7511
• Practice Address - Country: US
• Practice Address - Phone: 919-876-7807
• Practice Address - Fax: 919-876-8823
• EIN: <UNAVAIL>
• Is Organization Subpart?: No
• Enumeration Date: 2005-06-01
• Last Update Date: 2011-03-23

Provider Licenses

State	License ID	Taxonomies
NC	23576	174400000X
NC	31375	174400000X
NC	23533	174400000X
NC	34410	174400000X
NC	9500252	174400000X
NC	200100423	174400000X
NC	9800209	174400000X
NC	200200682	174400000X

Provider Taxonomies

Primary?	Code	Type	Classification	Specialization	Group
Yes	174400000X	Other Service Providers	Specialist		Group - Single Specialty

Provider Identifiers

State	Identifier ID	ID Type	Issuer
NC	6973447	Medicaid
NC	7902997	Medicaid
NC	8947988	Medicaid
NC	8947988	Medicaid
NC	D62808	Medicare UPIN
NC	2284903	Medicare ID - Type Unspecified	MEDICARE PROVIDER NUMBER
NC	G14096	Medicare UPIN
NC	2216087A	Medicare ID - Type Unspecified	MEDICARE PROVIDER NUMBER
NC	210045	Medicare ID - Type Unspecified	MEDICARE PROVIDER NUMBER
NC	6973447	Medicaid
NC	H36927	Medicare UPIN
NC	2158714	Medicare ID - Type Unspecified	MEDICARE PROVIDER NUMBER
NC	7902997	Medicaid
NC	C88532	Medicare UPIN
NC	H34073	Medicare UPIN
NC	2161684	Medicare ID - Type Unspecified	MEDICARE PROVIDER NUMBER
NC	207775B	Medicare ID - Type Unspecified	MEDICARE PROVIDER NUMBER
NC	D46166	Medicare UPIN
NC	I26516	Medicare UPIN
NC	0865	Medicare ID - Type Unspecified	GROUP NUMBER