NPIMap

Organization Active NPI

Lakeshore Pediatric Center, P.a.

  • Pediatrics Physician
  • Denver, NC
National Provider Identifier
1366650707
Registry record updated Feb 4, 2011
On this page

Key facts

NPPES NPI Registry
Primary specialty
Pediatrics PhysicianTaxonomy code 208000000X
License
2000-00103 Issued in NC
Legal business name
LAKESHORE PEDIATRIC CENTER, P.A.
Practice address
275 N Hwy 16
Suite: 103 Lakeshore Pediatric Center.
Denver, NC 28037
Phone
(704) 489-8401
Fax
(704) 489-8404
NPI assigned
May 18, 2007
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Feb 4, 2011

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Dr. Wissam Nadra, MDNPI 1154318350
Title
President
Phone
(704) 489-8401

Authorized official NPPES reports the official by name only. The link goes to the one practitioner connected to this organization with that name.

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Pediatrics PhysicianGroup: 193400000X SINGLE SPECIALTY GROUP 208000000X 2000-00103 NC Primary

Addresses

Primary practice location

275 N Hwy 16
Suite: 103 Lakeshore Pediatric Center.
Denver, NC 28037

Mailing address

275 N Hwy 16
Suite: 103 Lakeshore Pediatric Center.
Denver, NC 28037
Phone (704) 489-8401

Other identifiers 1

IdentifierTypeStateIssuer
5950140MedicaidNC

National Provider Directory

National Provider Directory

Locations

635 N NC 16 Business Hwy
Denver, NC 28037
Phone (704) 489-8401

Practitioners & affiliated clinicians

Practitioners 4

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1179446400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1296777600000",
    "number": "1366650707",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "275 N HWY 16",
            "address_2": "SUITE: 103 LAKESHORE PEDIATRIC CENTER.",
            "city": "DENVER",
            "state": "NC",
            "postal_code": "28037",
            "telephone_number": "704-489-8401",
            "fax_number": "704-489-8404"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "275 N HWY 16",
            "address_2": "SUITE: 103 LAKESHORE PEDIATRIC CENTER.",
            "city": "DENVER",
            "state": "NC",
            "postal_code": "28037",
            "telephone_number": "704-489-8401",
            "fax_number": "704-489-8404"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "LAKESHORE PEDIATRIC CENTER, P.A.",
        "organizational_subpart": "NO",
        "enumeration_date": "2007-05-18",
        "last_updated": "2011-02-04",
        "status": "A",
        "authorized_official_last_name": "NADRA",
        "authorized_official_first_name": "WISSAM",
        "authorized_official_title_or_position": "PRESIDENT",
        "authorized_official_telephone_number": "704-489-8401",
        "authorized_official_name_prefix": "Dr.",
        "authorized_official_credential": "MD"
    },
    "taxonomies": [
        {
            "code": "208000000X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Pediatrics",
            "state": "NC",
            "license": "2000-00103",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "5950140",
            "state": "NC"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Denver, NC

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Feb 4, 2011; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.