Provider Demographics
NPI:1649381344
Name:CARROLL, LISA BERTINA (PA C)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:BERTINA
Last Name:CARROLL
Suffix:
Gender:F
Credentials:PA C
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:BERTINA
Other - Last Name:JONES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:607 BARTON AVE
Mailing Address - Street 2:
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37405-4301
Mailing Address - Country:US
Mailing Address - Phone:801-879-1158
Mailing Address - Fax:
Practice Address - Street 1:2051 HAMILL ROAD
Practice Address - Street 2:STE 301 A
Practice Address - City:HIXSON
Practice Address - State:TN
Practice Address - Zip Code:37343
Practice Address - Country:US
Practice Address - Phone:423-870-3376
Practice Address - Fax:423-877-1387
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2012-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNPA0000001158207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
Q32509Medicare UPIN
TN3663615Medicare ID - Type Unspecified