Provider Demographics
NPI:1275504185
Name:BERES, MICHAEL WAYNE (FNP)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:WAYNE
Last Name:BERES
Suffix:
Gender:M
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 JOHNSON RIDGE MEDICAL PARK
Mailing Address - Street 2:
Mailing Address - City:ELKIN
Mailing Address - State:NC
Mailing Address - Zip Code:28621-2447
Mailing Address - Country:US
Mailing Address - Phone:336-526-4500
Mailing Address - Fax:
Practice Address - Street 1:400 JOHNSON RIDGE RD
Practice Address - Street 2:
Practice Address - City:ELKIN
Practice Address - State:NC
Practice Address - Zip Code:28621-2418
Practice Address - Country:US
Practice Address - Phone:336-526-4500
Practice Address - Fax:336-526-8626
Is Sole Proprietor?:No
Enumeration Date:2006-01-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC201050363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7003692Medicaid
NCS63543Medicare UPIN
NC7003692Medicaid