Provider Demographics
NPI:1720388192
Name:LEVINSON, LISA SHANE (FNP)
Entity Type:Individual
Prefix:MRS
First Name:LISA
Middle Name:SHANE
Last Name:LEVINSON
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:MRS
Other - First Name:LISA
Other - Middle Name:SHANE
Other - Last Name:LEVINSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:FNP
Mailing Address - Street 1:31 CROSSBOW DR
Mailing Address - Street 2:
Mailing Address - City:PENFIELD
Mailing Address - State:NY
Mailing Address - Zip Code:14526-9757
Mailing Address - Country:US
Mailing Address - Phone:585-787-2765
Mailing Address - Fax:
Practice Address - Street 1:811 RIDGE RD
Practice Address - Street 2:
Practice Address - City:WEBSTER
Practice Address - State:NY
Practice Address - Zip Code:14580-2401
Practice Address - Country:US
Practice Address - Phone:585-671-4660
Practice Address - Fax:585-671-4668
Is Sole Proprietor?:No
Enumeration Date:2010-11-01
Last Update Date:2023-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY336301363L00000X
NYF336301363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYF336301Medicaid