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NPI Code Detail

MEDICARE: DR. NANCY BROUS-DISTEFANO D.O.

MEDICARE: DR. NANCY BROUS-DISTEFANO D.O.
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
1207Q00000XFamily Medicine Physician200301208NC

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
11508821315OTHERNCNPI

General Provider Information

NPI Number : 1508821315
Entity Type Code : Individual
Provider Name (Legal Business Name) : DR. NANCY BROUS-DISTEFANO D.O.
Provider Business Mailing Address
First Line : 1380 COWELL FARM RD
Second Line :
City : WASHINGTON
State : NC
Zip : 27889-3431
Country : US
Telephone Number : 252-946-2101
Fax Number : 252-946-9071
Provider Business Practice Location Address
First Line : 1380 COWELL FARM RD
Second Line :
City : WASHINGTON
State : NC
Zip : 27889-3431
Country : US
Telephone Number : 252-946-2101
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 04/18/2006
Last Update Date : 04/26/2022

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