Healthcare Provider Details

I. General information

NPI: 1699762039
Provider Name (Legal Business Name): GINA LICAUSE MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/30/2005
Last Update Date: 09/27/2021
Certification Date: 05/03/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 E WT HARRIS BLVD STE 5002
CHARLOTTE NC
28262-3485
US

IV. Provider business mailing address

PO BOX 19305
CHARLOTTE NC
28219-9305
US

V. Phone/Fax

Practice location:
  • Phone: 704-801-7310
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number35695
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: