Provider Demographics
NPI:1710968557
Name:PENNINGTON, LISA (PA-C)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:PENNINGTON
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:PO BOX 1595
Mailing Address - Street 2:
Mailing Address - City:ASHLAND
Mailing Address - State:KY
Mailing Address - Zip Code:41105-1595
Mailing Address - Country:US
Mailing Address - Phone:606-836-3900
Mailing Address - Fax:606-836-0205
Practice Address - Street 1:2420 ARGILLITE RD STE B
Practice Address - Street 2:
Practice Address - City:FLATWOODS
Practice Address - State:KY
Practice Address - Zip Code:41139-1972
Practice Address - Country:US
Practice Address - Phone:606-836-3900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-09
Last Update Date:2022-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYPA303363A00000X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY95003166Medicaid
KY95003166Medicaid
KY000000615690OtherANTHEM BCBS
KYP00781363OtherRRMC
KY01258003Medicare PIN
KYP00781363OtherRRMC
KYP27883Medicare UPIN
KY95003166Medicaid
KY0216343Medicare PIN