Basic Information
| Provider Information | |||||||||
| NPI: | 1912523457 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ZINE | ||||||||
| FirstName: | DRISS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5 WEEPING BEECH WAY | ||||||||
| Address2: | |||||||||
| City: | DURHAM | ||||||||
| State: | NC | ||||||||
| PostalCode: | 277134369 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9196223978 | ||||||||
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| Practice Location | |||||||||
| Address1: | 4420 LAKE BOONE TRL | ||||||||
| Address2: | |||||||||
| City: | RALEIGH | ||||||||
| State: | NC | ||||||||
| PostalCode: | 276077505 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9197843100 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/21/2020 | ||||||||
| LastUpdateDate: | 07/31/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/31/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 5013226 | NC | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363LA2200X | 5013226 | NC | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health |
ID Information
| ID | Type | State | Issuer | Description | 5013226 | 05 | NC | MEDICAID |