Provider Demographics
NPI:1265494926
Name:FORD, LISA R (PA-C)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:R
Last Name:FORD
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:
Other - Last Name:BROWN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:300 GEORGE ST
Mailing Address - Street 2:PO BOX 9805
Mailing Address - City:NEW HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06511-6624
Mailing Address - Country:US
Mailing Address - Phone:203-785-7998
Mailing Address - Fax:
Practice Address - Street 1:800 HOWARD AVE
Practice Address - Street 2:
Practice Address - City:NEW HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06519-1369
Practice Address - Country:US
Practice Address - Phone:203-785-2140
Practice Address - Fax:203-785-6414
Is Sole Proprietor?:No
Enumeration Date:2006-04-06
Last Update Date:2021-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0016792471V0106X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No2471V0106XTechnologists, Technicians & Other Technical Service ProvidersRadiologic TechnologistVascular-Interventional Technology