Provider Demographics
NPI:1619973294
Name:CONNERY, LISA E (MD)
Entity Type:Individual
Prefix:MS
First Name:LISA
Middle Name:E
Last Name:CONNERY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:75 BEEKMAN STREET
Mailing Address - Street 2:
Mailing Address - City:PLATTSBURG
Mailing Address - State:NY
Mailing Address - Zip Code:12901-1438
Mailing Address - Country:US
Mailing Address - Phone:518-561-2000
Mailing Address - Fax:518-562-7542
Practice Address - Street 1:75 BEEKMAN STREET
Practice Address - Street 2:
Practice Address - City:PLATTSBURG
Practice Address - State:NY
Practice Address - Zip Code:12901-1438
Practice Address - Country:US
Practice Address - Phone:518-561-2000
Practice Address - Fax:518-562-7542
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-28
Last Update Date:2021-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA07981200207L00000X
NY189380207L00000X
CAG63224207RC0200X
FLME94486207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01829923Medicaid
NJ0149942Medicaid
NJ0149942Medicaid
NJ118740DBFMedicare PIN
NY0421SUMedicare ID - Type UnspecifiedGHI MEDICARE
NYE24993Medicare UPIN