Provider Demographics
NPI:1457548406
Name:WATAUGA LAKE FAMILY MEDICINE PC
Entity Type:Organization
Organization Name:WATAUGA LAKE FAMILY MEDICINE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:AMY
Authorized Official - Middle Name:R
Authorized Official - Last Name:MILLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:336-982-2158
Mailing Address - Street 1:138 N FORK NEW RIVER RD
Mailing Address - Street 2:
Mailing Address - City:LANSING
Mailing Address - State:NC
Mailing Address - Zip Code:28643-9130
Mailing Address - Country:US
Mailing Address - Phone:336-982-2158
Mailing Address - Fax:336-982-3373
Practice Address - Street 1:140 MCQUEEN ST.
Practice Address - Street 2:
Practice Address - City:BUTLER
Practice Address - State:TN
Practice Address - Zip Code:37640
Practice Address - Country:US
Practice Address - Phone:423-768-0195
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-03
Last Update Date:2007-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD0000041068207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty