Provider Demographics
NPI:1508821315
Name:BROUS-DISTEFANO, NANCY (DO)
Entity Type:Individual
Prefix:DR
First Name:NANCY
Middle Name:
Last Name:BROUS-DISTEFANO
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1380 COWELL FARM RD
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:27889-3431
Mailing Address - Country:US
Mailing Address - Phone:252-946-2101
Mailing Address - Fax:252-946-9071
Practice Address - Street 1:1380 COWELL FARM RD
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:NC
Practice Address - Zip Code:27889-3431
Practice Address - Country:US
Practice Address - Phone:252-946-2101
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-18
Last Update Date:2022-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC200301208207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1508821315OtherNPI
1282880007Medicare NSC
NCF27845Medicare UPIN