Provider Demographics
NPI:1619507423
Name:ELKIN, LISA MCGILLVARY
Entity Type:Individual
Prefix:MRS
First Name:LISA
Middle Name:MCGILLVARY
Last Name:ELKIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5916 FOSSIL RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:PLANO
Mailing Address - State:TX
Mailing Address - Zip Code:75093-7734
Mailing Address - Country:US
Mailing Address - Phone:972-904-2593
Mailing Address - Fax:
Practice Address - Street 1:5916 FOSSIL RIDGE DR
Practice Address - Street 2:
Practice Address - City:PLANO
Practice Address - State:TX
Practice Address - Zip Code:75093-7734
Practice Address - Country:US
Practice Address - Phone:972-904-2593
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-21
Last Update Date:2020-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX25103838172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver