Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 208200000X | Surgeon | 2018-01150 | NC |
Y | 208600000X | Surgeon | 2018-01150 | NC |
N | 2086S0102X | Surgical Critical Care | 03786 | KY |
N | 2086S0102X | Surgical Critical Care | 077615 | GA |
NPI | 1114160629 |
---|---|
Provider Name | Mack Drake |
First Address | Charlotte, NC 28275-1069 |
Second Address | Greenville, NC 27834 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 14/04/2009 |
Last Update Date | 20/02/2019 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
1114160629 | (05) | NC |
19XAV | BCBS OF NC (01) | NC |
NN2984A | MEDICARE (01) | NC |