Provider Demographics
NPI:1922407063
Name:WASOWICZ, MICHAEL (APRN)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:WASOWICZ
Suffix:
Gender:M
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2789
Mailing Address - Street 2:
Mailing Address - City:KITTY HAWK
Mailing Address - State:NC
Mailing Address - Zip Code:27949-2789
Mailing Address - Country:US
Mailing Address - Phone:928-231-1859
Mailing Address - Fax:
Practice Address - Street 1:315 GREENVILLE BLVD SE STE 100
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:NC
Practice Address - Zip Code:27858-5733
Practice Address - Country:US
Practice Address - Phone:252-917-5621
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-08-14
Last Update Date:2021-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAP7739363LF0000X
NC5011826363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily