Provider Demographics
NPI:1659456630
Name:MOORE, LISA M (PA-C)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:M
Last Name:MOORE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:324 GANNETT DR STE 200
Mailing Address - Street 2:
Mailing Address - City:SOUTH PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04106-3266
Mailing Address - Country:US
Mailing Address - Phone:207-482-7800
Mailing Address - Fax:207-482-7898
Practice Address - Street 1:690 MINOT AVE STE 1
Practice Address - Street 2:
Practice Address - City:AUBURN
Practice Address - State:ME
Practice Address - Zip Code:04210-3922
Practice Address - Country:US
Practice Address - Phone:207-783-1328
Practice Address - Fax:207-786-4332
Is Sole Proprietor?:No
Enumeration Date:2006-10-26
Last Update Date:2020-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9108417363A00000X
MA800363AS0400X
MEPA1497363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME1659456630Medicaid
MAAP081701Medicare PIN