MEDICARE: EVA MAE STASSEN FNP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LF0000X	Family Nurse Practitioner	201604	NC

General Provider Information

NPI Number	:	1265438089
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	EVA MAE STASSEN FNP

Provider Business Mailing Address
First Line	:	11216 STONY PATH DR
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28214-9287
Country	:	US
Telephone Number	:	704-391-2866
Fax Number	:

Provider Business Practice Location Address
First Line	:	3500 MOUNT HOLLY HUNTERSVILLE RD
Second Line	:	STE 200
City	:	CHARLOTTE
State	:	NC
Zip	:	28216-8644
Country	:	US
Telephone Number	:	704-399-7800
Fax Number	:	704-399-7717

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/27/2005
Last Update Date	:	07/08/2007

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