Provider Demographics
NPI:1285748442
Name:FARIBAULT, WALTER
Entity type:Individual
Prefix:
First Name:WALTER
Middle Name:
Last Name:FARIBAULT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:114 DUMONT DR
Mailing Address - Street 2:
Mailing Address - City:HILLSBOROUGH
Mailing Address - State:NC
Mailing Address - Zip Code:27278-7100
Mailing Address - Country:US
Mailing Address - Phone:919-732-8016
Mailing Address - Fax:
Practice Address - Street 1:1765 DOBBINS DR
Practice Address - Street 2:
Practice Address - City:CHAPEL HILL
Practice Address - State:NC
Practice Address - Zip Code:27514-5876
Practice Address - Country:US
Practice Address - Phone:919-929-5402
Practice Address - Fax:919-933-5271
Is Sole Proprietor?:No
Enumeration Date:2006-08-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC100108363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant