Provider Demographics
NPI:1982854774
Name:MATUGA, LISA MICHELLE (LISA MATUGA, PA-C)
Entity Type:Individual
Prefix:MS
First Name:LISA
Middle Name:MICHELLE
Last Name:MATUGA
Suffix:
Gender:F
Credentials:LISA MATUGA, PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15830 BALLANTYNE MEDICAL PL
Mailing Address - Street 2:STE 100
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28277-0762
Mailing Address - Country:US
Mailing Address - Phone:704-667-2650
Mailing Address - Fax:704-544-0172
Practice Address - Street 1:14214 BALLANTYNE LAKE RD
Practice Address - Street 2:SUITE 100
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28277-3373
Practice Address - Country:US
Practice Address - Phone:704-667-2650
Practice Address - Fax:704-544-0172
Is Sole Proprietor?:No
Enumeration Date:2008-09-29
Last Update Date:2017-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601005362363AM0700X
NC0010-02499363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8101140Medicaid
NC2762539CMedicare PIN
NC2762539NMedicare PIN
NC2762539Medicare PIN
NC2762539IMedicare PIN
NC2762539LMedicare PIN
NC2762539MMedicare PIN
NC8101140Medicaid
NC2762539BMedicare PIN
NC2762539JMedicare PIN
NC2762539KMedicare PIN
NC2762539HMedicare PIN
NC2762539DMedicare PIN
NC2762539EMedicare PIN
NC2762539FMedicare PIN
NC2762539AMedicare PIN
NC2762539OMedicare PIN