Provider Demographics
NPI:1871027441
Name:MATOS, LISVEL
Entity Type:Individual
Prefix:
First Name:LISVEL
Middle Name:
Last Name:MATOS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:249 BILLINGSLEY RD
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28211-1003
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:249 BILLINGSLEY RD
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28211-1003
Practice Address - Country:US
Practice Address - Phone:980-314-9138
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-04-20
Last Update Date:2017-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5009422363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health