Provider Demographics
NPI:1497748263
Name:GERGEN, LISA RAE (APRN)
Entity Type:Individual
Prefix:MS
First Name:LISA
Middle Name:RAE
Last Name:GERGEN
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:MS
Other - First Name:LISA
Other - Middle Name:R
Other - Last Name:SIRONEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:560 S LOOP RD
Mailing Address - Street 2:
Mailing Address - City:EDGEWOOD
Mailing Address - State:KY
Mailing Address - Zip Code:41017-3405
Mailing Address - Country:US
Mailing Address - Phone:859-301-2663
Mailing Address - Fax:859-301-0655
Practice Address - Street 1:560 S LOOP RD
Practice Address - Street 2:
Practice Address - City:EDGEWOOD
Practice Address - State:KY
Practice Address - Zip Code:41017-3405
Practice Address - Country:US
Practice Address - Phone:859-301-2663
Practice Address - Fax:859-301-0655
Is Sole Proprietor?:No
Enumeration Date:2005-08-26
Last Update Date:2016-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRN-232372363LF0000X
KY1067394363LF0000X
KY3003813363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
2442191OtherUHC
OH2535028Medicaid
KY78008083Medicaid
000000248062OtherANTHEM
P65717OtherUPIN
500027765OtherMEDICARE RR
OH2535028Medicaid
OHH406770Medicare PIN
KYK119990Medicare PIN
000000248062OtherANTHEM