Provider Demographics
NPI:1245405729
Name:KING, LISA ANN (PA)
Entity Type:Individual
Prefix:MS
First Name:LISA
Middle Name:ANN
Last Name:KING
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7301 STONEROCK CIR
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32819-8004
Mailing Address - Country:US
Mailing Address - Phone:407-298-6950
Mailing Address - Fax:407-578-2354
Practice Address - Street 1:7301 STONEROCK CIR
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32819-8004
Practice Address - Country:US
Practice Address - Phone:407-298-6950
Practice Address - Fax:407-578-2354
Is Sole Proprietor?:No
Enumeration Date:2008-04-25
Last Update Date:2016-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA 2547363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL004694300Medicaid
FLPA2547OtherMEDICAL LICENSE
FLPA2547OtherMEDICAL LICENSE