Provider Demographics
NPI:1326167925
Name:DAVIS, LISA CHANDLER (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:LISA
Middle Name:CHANDLER
Last Name:DAVIS
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:M
Other - Middle Name:LISA
Other - Last Name:ROY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:PO BOX 18563
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27619-8563
Mailing Address - Country:US
Mailing Address - Phone:919-782-1806
Mailing Address - Fax:919-782-1669
Practice Address - Street 1:3521 HAWORTH DR
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27609-7216
Practice Address - Country:US
Practice Address - Phone:919-782-1806
Practice Address - Fax:919-782-4756
Is Sole Proprietor?:No
Enumeration Date:2007-03-28
Last Update Date:2009-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC102668363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
970018198OtherRAILROAD MEDICARE
970018198OtherRAILROAD MEDICARE
R77509Medicare UPIN