Provider Demographics
NPI:1083655724
Name:ELGIN, LISA B (NP)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:B
Last Name:ELGIN
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1100
Mailing Address - Street 2:
Mailing Address - City:MAGEE
Mailing Address - State:MS
Mailing Address - Zip Code:39111-1100
Mailing Address - Country:US
Mailing Address - Phone:662-369-9500
Mailing Address - Fax:
Practice Address - Street 1:403 S CHESTNUT ST
Practice Address - Street 2:
Practice Address - City:ABERDEEN
Practice Address - State:MS
Practice Address - Zip Code:39730-3334
Practice Address - Country:US
Practice Address - Phone:662-369-9500
Practice Address - Fax:662-369-0260
Is Sole Proprietor?:No
Enumeration Date:2006-06-10
Last Update Date:2015-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR826442363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS01733711Medicaid
MS01733711Medicaid
500001466Medicare ID - Type Unspecified