Provider Demographics
NPI:1093740029
Name:MCPHERSON, VANESSA LEE (MD)
Entity Type:Individual
Prefix:
First Name:VANESSA
Middle Name:LEE
Last Name:MCPHERSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 751649
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28275-1649
Mailing Address - Country:US
Mailing Address - Phone:843-789-1620
Mailing Address - Fax:843-724-2440
Practice Address - Street 1:1807 CROWNE COMMONS WAY
Practice Address - Street 2:
Practice Address - City:JOHNS ISLAND
Practice Address - State:SC
Practice Address - Zip Code:29455-4931
Practice Address - Country:US
Practice Address - Phone:843-203-2280
Practice Address - Fax:843-203-2281
Is Sole Proprietor?:No
Enumeration Date:2006-07-11
Last Update Date:2023-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC17934207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC179345Medicaid
SC179345Medicaid
NC8910685Medicaid
NC080172530Medicare PIN
NC2240665BMedicare PIN
NC8910685Medicaid
NCNCC039BMedicare PIN
NC2240665EMedicare PIN
NCG20796Medicare UPIN