Provider Demographics
NPI:1730663287
Name:BAILEY, LISA S (PA)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:S
Last Name:BAILEY
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:S
Other - Last Name:ISRAEL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:1195 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02904-1824
Mailing Address - Country:US
Mailing Address - Phone:401-861-3782
Mailing Address - Fax:401-383-5846
Practice Address - Street 1:1195 N MAIN ST
Practice Address - Street 2:
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02904-1824
Practice Address - Country:US
Practice Address - Phone:401-861-3782
Practice Address - Fax:401-861-3782
Is Sole Proprietor?:No
Enumeration Date:2018-09-20
Last Update Date:2020-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIPA01080363AM0700X
363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical