Provider Demographics
NPI:1437185410
Name:RAY, LISA MARIE (PA)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:MARIE
Last Name:RAY
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:PO BOX 863026
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32886-3026
Mailing Address - Country:US
Mailing Address - Phone:800-288-8325
Mailing Address - Fax:419-866-5453
Practice Address - Street 1:1 SHIRCLIFF WAY
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32204
Practice Address - Country:US
Practice Address - Phone:904-308-7300
Practice Address - Fax:912-355-5324
Is Sole Proprietor?:No
Enumeration Date:2006-06-23
Last Update Date:2013-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA004601363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA816135739Medicaid
GA97WCGVGMedicare ID - Type Unspecified
Q50312Medicare UPIN