Provider Demographics
NPI:1346356524
Name:LISENBY, CATHY DIANE (PA-C)
Entity Type:Individual
Prefix:MS
First Name:CATHY
Middle Name:DIANE
Last Name:LISENBY
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:5100 LAKE TER NE STE WC
Mailing Address - Street 2:
Mailing Address - City:MOUNT VERNON
Mailing Address - State:IL
Mailing Address - Zip Code:62864-9665
Mailing Address - Country:US
Mailing Address - Phone:618-899-5001
Mailing Address - Fax:618-242-5152
Practice Address - Street 1:2 GOOD SAMARITAN WAY
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:IL
Practice Address - Zip Code:62864-2408
Practice Address - Country:US
Practice Address - Phone:618-899-4000
Practice Address - Fax:618-899-4790
Is Sole Proprietor?:No
Enumeration Date:2006-08-21
Last Update Date:2020-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0850001397363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILP78384Medicare UPIN
IL204383Medicare ID - Type UnspecifiedPROVIDER NUMBER