Provider Demographics
NPI:1336116433
Name:LISCH, GINA (NP)
Entity Type:Individual
Prefix:
First Name:GINA
Middle Name:
Last Name:LISCH
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 CVS DR
Mailing Address - Street 2:
Mailing Address - City:WOONSOCKET
Mailing Address - State:RI
Mailing Address - Zip Code:02895-6146
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:15474 W GREENWAY RD
Practice Address - Street 2:
Practice Address - City:SURPRISE
Practice Address - State:AZ
Practice Address - Zip Code:85374-4348
Practice Address - Country:US
Practice Address - Phone:623-584-1964
Practice Address - Fax:623-544-2359
Is Sole Proprietor?:No
Enumeration Date:2006-03-07
Last Update Date:2021-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARN297329NP5983363LF0000X
OHRN155396NP07758363LF0000X
AZRN138704AP2390363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH341458069GLOtherSUMMA INSURANCE
OH2521462Medicaid
OHNP16803Medicare PIN
OHNP16802Medicare PIN
OH341458069GLOtherSUMMA INSURANCE
OHP73638Medicare UPIN