Provider Demographics
NPI:1427027648
Name:FOX, LISA MARIE (PA C)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:MARIE
Last Name:FOX
Suffix:
Gender:F
Credentials:PA C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2002 MEDICAL PARKWAY
Mailing Address - Street 2:SUITE #430
Mailing Address - City:ANNAPOLIS
Mailing Address - State:MD
Mailing Address - Zip Code:21401
Mailing Address - Country:US
Mailing Address - Phone:410-266-2740
Mailing Address - Fax:410-266-2753
Practice Address - Street 1:2002 MEDICAL PKWY
Practice Address - Street 2:SUITE #430
Practice Address - City:ANNAPOLIS
Practice Address - State:MD
Practice Address - Zip Code:21401
Practice Address - Country:US
Practice Address - Phone:410-266-2740
Practice Address - Fax:410-266-2753
Is Sole Proprietor?:No
Enumeration Date:2006-03-17
Last Update Date:2011-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC0003269363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDC0003269OtherPAC LICENSE