Provider Demographics
NPI:1033102389
Name:PETRI, LISA ANNE (MD)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:ANNE
Last Name:PETRI
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:ANNE
Other - Last Name:GLEIM
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 751803
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28275-1803
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:207 MEDICAL ST
Practice Address - Street 2:
Practice Address - City:PILOT MOUNTAIN
Practice Address - State:NC
Practice Address - Zip Code:27041-8656
Practice Address - Country:US
Practice Address - Phone:336-368-5011
Practice Address - Fax:336-368-1424
Is Sole Proprietor?:No
Enumeration Date:2005-08-23
Last Update Date:2020-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC01562207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC2004-01562Medicaid
NC2004-01562Medicaid
2035798Medicare ID - Type Unspecified