Provider Demographics
NPI:1710905971
Name:OCONNOR, LISA (MOTRL)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:OCONNOR
Suffix:
Gender:F
Credentials:MOTRL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2410 LORD ANSON DR
Mailing Address - Street 2:
Mailing Address - City:WAXHAW
Mailing Address - State:NC
Mailing Address - Zip Code:28173-6808
Mailing Address - Country:US
Mailing Address - Phone:704-651-5148
Mailing Address - Fax:704-243-6137
Practice Address - Street 1:2410 LORD ANSON DR
Practice Address - Street 2:
Practice Address - City:WAXHAW
Practice Address - State:NC
Practice Address - Zip Code:28173-6808
Practice Address - Country:US
Practice Address - Phone:704-651-5148
Practice Address - Fax:704-243-6137
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5842171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7301855Medicaid