Basic Information
| Provider Information | |||||||||
| NPI: | 1881154987 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MORTENSEN | ||||||||
| FirstName: | XAVIER | ||||||||
| MiddleName: | MAX | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5151 BIOINFORMATICS BLDG CB 7040 | ||||||||
| Address2: | |||||||||
| City: | CHAPEL HILL | ||||||||
| State: | NC | ||||||||
| PostalCode: | 275997040 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9198430264 | ||||||||
| FaxNumber: | 9199661908 | ||||||||
| Practice Location | |||||||||
| Address1: | 2226 NELSON HWY STE 200 | ||||||||
| Address2: | |||||||||
| City: | CHAPEL HILL | ||||||||
| State: | NC | ||||||||
| PostalCode: | 275179638 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9849742020 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/23/2019 | ||||||||
| LastUpdateDate: | 06/16/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 06/16/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 390200000X | 262210 | NC | Y | Student, Health Care | Student in an Organized Health Care Education/Training Program |
No ID Information.