Provider Demographics
NPI:1639944382
Name:PARK, LISA MARIE (FNP-BC)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:MARIE
Last Name:PARK
Suffix:
Gender:F
Credentials:FNP-BC
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 285
Mailing Address - Street 2:
Mailing Address - City:TRIADELPHIA
Mailing Address - State:WV
Mailing Address - Zip Code:26059-0285
Mailing Address - Country:US
Mailing Address - Phone:304-639-0873
Mailing Address - Fax:
Practice Address - Street 1:4509 NATIONAL RD
Practice Address - Street 2:
Practice Address - City:TRIADELPHIA
Practice Address - State:WV
Practice Address - Zip Code:26059-2013
Practice Address - Country:US
Practice Address - Phone:304-639-0873
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-11-21
Last Update Date:2023-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV117804207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine