Provider Demographics
NPI:1679504104
Name:FENG, LISA QI (MD)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:QI
Last Name:FENG
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:QI
Other - Middle Name:LISA
Other - Last Name:FENG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 7068
Mailing Address - Street 2:
Mailing Address - City:PORTSMOUTH
Mailing Address - State:VA
Mailing Address - Zip Code:23707-0068
Mailing Address - Country:US
Mailing Address - Phone:757-686-3508
Mailing Address - Fax:757-686-0541
Practice Address - Street 1:1168 FIRST COLONIAL RD STE 201
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23454-2444
Practice Address - Country:US
Practice Address - Phone:757-481-1113
Practice Address - Fax:757-496-3822
Is Sole Proprietor?:No
Enumeration Date:2006-07-05
Last Update Date:2018-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY33968207R00000X
VA0101265741207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY110186653OtherRR MEDICARE PIN
KY36000818OtherASC MEDICAID GROUP
KY4000501OtherMEDICARE LAB GROUP
KY37903705OtherMEDICAID LAB GROUP
KYASC1019OtherASC MEDICARE GROUP
KYCC4966OtherRR MEDICARE GROUP
KY64339682Medicaid
KY0624412Medicare ID - Type Unspecified
KY64339682Medicaid
KYASC1019OtherASC MEDICARE GROUP