Basic Information
| Provider Information | |||||||||
| NPI: | 1659334423 | ||||||||
| EntityType: | 1 | ||||||||
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| LastName: | EFREMOV | ||||||||
| FirstName: | MAXIM | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | ACNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | MEDICAL CENTER BLVD | ||||||||
| Address2: | WAKE FOREST UNIVERSITY HEALTH SCIENCES | ||||||||
| City: | WINSTON SALEM | ||||||||
| State: | NC | ||||||||
| PostalCode: | 271570001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3367162011 | ||||||||
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| Practice Location | |||||||||
| Address1: | MEDICAL CENTER BLVD | ||||||||
| Address2: | WAKE FOREST UNIVERSITY HEALTH SCIENCES | ||||||||
| City: | WINSTON SALEM | ||||||||
| State: | NC | ||||||||
| PostalCode: | 271570001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3367162011 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/11/2006 | ||||||||
| LastUpdateDate: | 03/04/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LA2100X | R45111 | NM | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Acute Care | 363LA2100X | CNP01073 | NM | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Acute Care | 363LA2100X | 5006044 | NC | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Acute Care |
ID Information
| ID | Type | State | Issuer | Description | NPI & TIN | 01 | NM | BCBS OF NM | OTHER | 99609754 | 05 | NM | MEDICAID |