Provider Demographics
NPI:1376631903
Name:THOMPSON, LISA HICKS (PA)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:HICKS
Last Name:THOMPSON
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2476 CANTON RD
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30066-5377
Mailing Address - Country:US
Mailing Address - Phone:812-246-9809
Mailing Address - Fax:770-573-9513
Practice Address - Street 1:2700 VISSING PARK RD
Practice Address - Street 2:
Practice Address - City:JEFFERSONVILLE
Practice Address - State:IN
Practice Address - Zip Code:47130-5989
Practice Address - Country:US
Practice Address - Phone:812-246-9809
Practice Address - Fax:770-573-9513
Is Sole Proprietor?:No
Enumeration Date:2006-10-10
Last Update Date:2021-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA03855363A00000X
IN10001505A363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN300011148Medicaid
TX190024301Medicaid
TX190024302Medicaid
TX190024303Medicaid
TX8K1609Medicare PIN
TX8F7026Medicare PIN
TXQ13696Medicare UPIN
TX190024303Medicaid
TX8K1608Medicare PIN
TX8F7031Medicare PIN
TX8F7017Medicare PIN