MEDICARE: JERRI NICOLE MASANOVICH NP

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	207Q00000X	Family Medicine Physician	22146	SC

General Provider Information

NPI Number	:	1366922866
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JERRI NICOLE MASANOVICH NP

Provider Business Mailing Address
First Line	:	1209 LOWNSDALE RD
Second Line	:
City	:	WEST COLUMBIA
State	:	SC
Zip	:	29170-3178
Country	:	US
Telephone Number	:	803-920-6376
Fax Number	:

Provider Business Practice Location Address
First Line	:	171B MONROE LN
Second Line	:
City	:	LEXINGTON
State	:	SC
Zip	:	29072-3904
Country	:	US
Telephone Number	:	803-358-8496
Fax Number	:	866-614-3887

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

Provider Enumeration Date	:	08/15/2018
Last Update Date	:	11/19/2021

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