Basic Information
Provider Information | |||||||||
NPI: | 1891778262 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | HERTZ | ||||||||
FirstName: | NATALIA | ||||||||
MiddleName: | GOETZ | ||||||||
NamePrefix: | MRS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | BCFNP | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | GOETZ | ||||||||
OtherFirstName: | NATALIA | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: | MS. | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 6035 FAIRVIEW RD | ||||||||
Address2: |   | ||||||||
City: | CHARLOTTE | ||||||||
State: | NC | ||||||||
PostalCode: | 282103256 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7042953000 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 724 AUBREY BELL DR | ||||||||
Address2: |   | ||||||||
City: | MATTHEWS | ||||||||
State: | NC | ||||||||
PostalCode: | 281055055 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7042953550 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/21/2005 | ||||||||
LastUpdateDate: | 04/26/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 04/26/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 0024166742 | VA | N |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363LF0000X | 0050-03620 | NC | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
ID | Type | State | Issuer | Description | P01309686 | 01 | NC | MEDICARE RAILROAD | OTHER | 30159536 | 01 | SC | SELECT HEALTH | OTHER | 7005152 | 05 | NC |   | MEDICAID | 1046727 | 01 | SC | WELLCARE OF SC | OTHER | 7364986 | 01 |   | AETNA | OTHER | 17812 | 01 | NC | BCBSNC | OTHER | NP1396 | 05 | SC |   | MEDICAID |