Provider Demographics
NPI:1093967408
Name:LIGHTHOUSE FAMILY MEDICINE, PLLC
Entity Type:Organization
Organization Name:LIGHTHOUSE FAMILY MEDICINE, PLLC
Other - Org Name:LISA C. NELSON, MD
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:LISA
Authorized Official - Middle Name:CARRAWAY
Authorized Official - Last Name:NELSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:252-948-1393
Mailing Address - Street 1:1005 BROWN ST
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:27889-4670
Mailing Address - Country:US
Mailing Address - Phone:252-948-1393
Mailing Address - Fax:
Practice Address - Street 1:1005 BROWN ST
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:NC
Practice Address - Zip Code:27889-4670
Practice Address - Country:US
Practice Address - Phone:252-948-1393
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-16
Last Update Date:2008-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC207-00955261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC146HHOtherBLUE CROSS
NC5908673Medicaid
NC2074087Medicare UPIN