Provider Demographics
NPI:1275509416
Name:HAWTHORNE, LISA (ANP)
Entity Type:Individual
Prefix:MRS
First Name:LISA
Middle Name:
Last Name:HAWTHORNE
Suffix:
Gender:F
Credentials:ANP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:260 TOWNSHIP BLVD
Mailing Address - Street 2:STE 20
Mailing Address - City:CAMILLUS
Mailing Address - State:NY
Mailing Address - Zip Code:13031-1674
Mailing Address - Country:US
Mailing Address - Phone:315-708-0190
Mailing Address - Fax:315-488-3284
Practice Address - Street 1:260 TOWNSHIP BLVD
Practice Address - Street 2:STE 20
Practice Address - City:CAMILLUS
Practice Address - State:NY
Practice Address - Zip Code:13031-1674
Practice Address - Country:US
Practice Address - Phone:315-708-0091
Practice Address - Fax:315-708-0194
Is Sole Proprietor?:No
Enumeration Date:2006-02-27
Last Update Date:2016-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF302679-1363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02410204Medicaid
NY02410204Medicaid
NYJ400089774Medicare PIN