Provider Demographics
NPI:1861564924
Name:WAKELON INTERNAL MEDICINE PLLC
Entity type:Organization
Organization Name:WAKELON INTERNAL MEDICINE PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD
Authorized Official - Prefix:MS
Authorized Official - First Name:SHELLY
Authorized Official - Middle Name:LORRAINE
Authorized Official - Last Name:WEST
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:919-269-0390
Mailing Address - Street 1:301 HOSPITAL ROAD
Mailing Address - Street 2:
Mailing Address - City:ZEBULON
Mailing Address - State:NC
Mailing Address - Zip Code:27597
Mailing Address - Country:US
Mailing Address - Phone:919-269-0390
Mailing Address - Fax:919-269-6868
Practice Address - Street 1:301 HOSPITAL ROAD
Practice Address - Street 2:
Practice Address - City:ZEBULON
Practice Address - State:NC
Practice Address - Zip Code:27597
Practice Address - Country:US
Practice Address - Phone:919-269-0390
Practice Address - Fax:919-269-6868
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-14
Last Update Date:2007-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC200001025207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC127GVOtherBC
NC2022572OtherUNITED HEALTH CARE
NC89127GVMedicaid
NC2077334OtherFIRST HEALTH
NCP00255758OtherRR MEDICARE
NC7632748OtherAETNA
NC2077334OtherFIRST HEALTH
NC89127GVMedicaid