Provider Demographics
NPI:1942251251
Name:WESTERN WAKE PEDIATRICS, PA
Entity Type:Organization
Organization Name:WESTERN WAKE PEDIATRICS, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:NATACHA
Authorized Official - Middle Name:
Authorized Official - Last Name:BUENO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:919-858-4925
Mailing Address - Street 1:940 SE CARY PARKWAY
Mailing Address - Street 2:SUITE 200
Mailing Address - City:CARY
Mailing Address - State:NC
Mailing Address - Zip Code:27511
Mailing Address - Country:US
Mailing Address - Phone:919-859-9991
Mailing Address - Fax:919-859-6595
Practice Address - Street 1:940 SE CARY PARKWAY
Practice Address - Street 2:SUITE 200
Practice Address - City:CARY
Practice Address - State:NC
Practice Address - Zip Code:27511
Practice Address - Country:US
Practice Address - Phone:919-859-9991
Practice Address - Fax:919-859-6595
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-12
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5902765Medicaid