MEDICARE: LISA M NANOVIC DO

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	207R00000X	Internal Medicine Physician	2009-01980	NC
2	207RN0300X	Nephrology Physician	2009-01980	NC

General Provider Information

NPI Number	:	1710948179
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LISA M NANOVIC DO

Provider Business Mailing Address
First Line	:	PO BOX 19305
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28219-9305
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	4525 CAMERON VALLEY PKWY
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28211-4369
Country	:	US
Telephone Number	:	704-512-3800
Fax Number	:

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

Provider Enumeration Date	:	03/28/2006
Last Update Date	:	07/15/2024

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