Basic Information
Provider Information
NPI: 1033487806
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: ANDERSON
FirstName: GREGORY
MiddleName: THOMAS
NamePrefix: MR.
NameSuffix:  
Credential: NP-C
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: PO BOX 936857
Address2:  
City: ATLANTA
State: GA
PostalCode: 311936857
CountryCode: US
TelephoneNumber: 9106629500
FaxNumber: 9106629501
Practice Location
Address1: 3000 NEW BERN AVE
Address2:  
City: RALEIGH
State: NC
PostalCode: 276101231
CountryCode: US
TelephoneNumber: 9193508000
FaxNumber:  
Other Information
ProviderEnumerationDate: 12/08/2011
LastUpdateDate: 04/28/2022
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: M
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: Y
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate: 04/28/2022

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
363L00000X5005436NCN Physician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner 
363LA2200X5005436NCY Physician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health

ID Information
IDTypeStateIssuerDescription
103348780605NC MEDICAID


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