Provider Demographics
NPI:1083670921
Name:JERNIGAN, LISA MARIE (MD)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:MARIE
Last Name:JERNIGAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:55 BUCKEYE COVE RD
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:NC
Mailing Address - Zip Code:28716-4511
Mailing Address - Country:US
Mailing Address - Phone:828-648-0282
Mailing Address - Fax:828-648-3479
Practice Address - Street 1:55 BUCKEYE COVE RD
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:NC
Practice Address - Zip Code:28716-4511
Practice Address - Country:US
Practice Address - Phone:828-648-0282
Practice Address - Fax:828-648-3479
Is Sole Proprietor?:No
Enumeration Date:2006-04-20
Last Update Date:2022-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME48831207Q00000X
NC2015-00012207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL044816800Medicaid
FLD20722Medicare UPIN