Basic Information
| Provider Information | |||||||||
| NPI: | 1659532182 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BULLOCK | ||||||||
| FirstName: | NICOLE | ||||||||
| MiddleName: | P | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2000 PERIMETER PARK DR STE 200 | ||||||||
| Address2: | |||||||||
| City: | MORRISVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 275608442 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9842154110 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1120 SE CARY PKWY | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | CARY | ||||||||
| State: | NC | ||||||||
| PostalCode: | 275187413 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9194674992 | ||||||||
| FaxNumber: | 9192325328 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/18/2008 | ||||||||
| LastUpdateDate: | 05/06/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/06/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208100000X | 0101243677 | VA | N | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation | 208100000X | 2009-01450 | NC | Y | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation |
ID Information
| ID | Type | State | Issuer | Description | -017 | 01 | VA | TRICARE | OTHER | 2181249 | 01 | VA | UHC/MAMSI | OTHER | PAR | 01 | VA | FIRST HEALTH COMMERCIAL | OTHER | PAR | 01 | VA | VA PREMIER HEALTH | OTHER | PAR | 01 | VA | VA HEALTH NETWORK | OTHER | 10036799 | 01 | VA | SENTARA/OPTIMA | OTHER | 5909717 | 05 | NC | MEDICAID | 1100205 | 01 | VA | USA MANAGED CARE | OTHER | 7285322 | 01 | VA | CIGNA | OTHER | 9280154 | 01 | VA | AETNA | OTHER | PAR | 01 | VA | CORVEL/CORCARE | OTHER | PAR | 01 | VA | MULTIPLAN | OTHER | 358459 | 01 | VA | ANTHEM | OTHER | 09717 | 01 | NC | NC BC/BS | OTHER | 1659532182 | 05 | VA | MEDICAID |