Provider Demographics
NPI:1033469648
Name:MACKNAIR, LISA M (PA-C)
Entity Type:Individual
Prefix:MS
First Name:LISA
Middle Name:M
Last Name:MACKNAIR
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:M
Other - Last Name:SHUBERT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:460 SOUTHBRIDGE ST
Mailing Address - Street 2:READYMED
Mailing Address - City:AUBURN
Mailing Address - State:MA
Mailing Address - Zip Code:01501-2442
Mailing Address - Country:US
Mailing Address - Phone:774-221-5135
Mailing Address - Fax:774-221-5136
Practice Address - Street 1:630 PLANTATION ST FL ST12
Practice Address - Street 2:
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01605-2038
Practice Address - Country:US
Practice Address - Phone:774-261-1356
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-09-12
Last Update Date:2015-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAPA4505363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical