MEDICARE: MS. LISA MICHELLE MATUGA LISA MATUGA, PA-C

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	363AM0700X	Medical Physician Assistant	5601005362	MI
2	363AM0700X	Medical Physician Assistant	0010-02499	NC

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1982854774
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. LISA MICHELLE MATUGA LISA MATUGA, PA-C

Provider Business Mailing Address
First Line	:	15830 BALLANTYNE MEDICAL PL
Second Line	:	STE 100
City	:	CHARLOTTE
State	:	NC
Zip	:	28277-0762
Country	:	US
Telephone Number	:	704-667-2650
Fax Number	:	704-544-0172

Provider Business Practice Location Address
First Line	:	14214 BALLANTYNE LAKE RD
Second Line	:	SUITE 100
City	:	CHARLOTTE
State	:	NC
Zip	:	28277-3373
Country	:	US
Telephone Number	:	704-667-2650
Fax Number	:	704-544-0172

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

Provider Enumeration Date	:	09/29/2008
Last Update Date	:	02/07/2017

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