Provider Demographics
NPI:1073568630
Name:CARR, LISA S (CNP)
Entity Type:Individual
Prefix:MRS
First Name:LISA
Middle Name:S
Last Name:CARR
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:PO BOX 2357
Mailing Address - Street 2:THOMASVILLE
Mailing Address - City:THOMASVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:31799-2357
Mailing Address - Country:US
Mailing Address - Phone:229-226-8800
Mailing Address - Fax:229-226-8232
Practice Address - Street 1:918 S BROAD ST
Practice Address - Street 2:THOMASVILLE
Practice Address - City:THOMASVILLE
Practice Address - State:GA
Practice Address - Zip Code:31792-0918
Practice Address - Country:US
Practice Address - Phone:229-226-8800
Practice Address - Fax:229-226-8232
Is Sole Proprietor?:No
Enumeration Date:2006-05-23
Last Update Date:2013-08-13
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
GARN077674363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00481698DMedicaid
GA00481698BMedicaid
S76047Medicare UPIN
GA00481698DMedicaid
GA50BBCRM01Medicare ID - Type UnspecifiedTHOMASVILLE