Provider Demographics
NPI:1689965162
Name:LAZESKI, ALICIA HARRISON (MD)
Entity Type:Individual
Prefix:DR
First Name:ALICIA
Middle Name:HARRISON
Last Name:LAZESKI
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:ALICIA
Other - Middle Name:LYNNE
Other - Last Name:HARRISON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:4601 PARK RD
Mailing Address - Street 2:SUITE 250
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28209-3239
Mailing Address - Country:US
Mailing Address - Phone:704-323-2000
Mailing Address - Fax:
Practice Address - Street 1:15825 BALLANTYNE MEDICAL PL STE 100
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28277-0745
Practice Address - Country:US
Practice Address - Phone:704-323-3400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-05-02
Last Update Date:2019-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2015-01567208100000X, 208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1689965162Medicaid
NC0397730004Medicare NSC