Provider Demographics
NPI:1669547766
Name:WAKE NEUROLOGY PLLC
Entity type:Organization
Organization Name:WAKE NEUROLOGY PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE ADMINISTRATOR/NURSE
Authorized Official - Prefix:MRS
Authorized Official - First Name:KRISTY
Authorized Official - Middle Name:
Authorized Official - Last Name:DRISKELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:919-463-1101
Mailing Address - Street 1:1110 SE CARY PKWY
Mailing Address - Street 2:SUITE 206
Mailing Address - City:CARY
Mailing Address - State:NC
Mailing Address - Zip Code:27518-7420
Mailing Address - Country:US
Mailing Address - Phone:919-463-1101
Mailing Address - Fax:919-463-1110
Practice Address - Street 1:1110 SE CARY PKWY
Practice Address - Street 2:SUITE 206
Practice Address - City:CARY
Practice Address - State:NC
Practice Address - Zip Code:27518-7420
Practice Address - Country:US
Practice Address - Phone:919-463-1101
Practice Address - Fax:919-463-1110
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-22
Last Update Date:2014-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC24232084S0012X
NC2004002172084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Multi-Specialty
No2084S0012XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologySleep MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5903406Medicaid
NCG47452Medicare UPIN
NC2025403BMedicare PIN