Provider Demographics
NPI:1760461016
Name:HUBBARD, LISA DIANNE HATCH (PA)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:DIANNE HATCH
Last Name:HUBBARD
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:813 E WOOD ST
Mailing Address - Street 2:
Mailing Address - City:PARIS
Mailing Address - State:TN
Mailing Address - Zip Code:38242-4223
Mailing Address - Country:US
Mailing Address - Phone:731-924-2000
Mailing Address - Fax:731-653-0053
Practice Address - Street 1:813 E WOOD ST
Practice Address - Street 2:
Practice Address - City:PARIS
Practice Address - State:TN
Practice Address - Zip Code:38242-4223
Practice Address - Country:US
Practice Address - Phone:731-924-2000
Practice Address - Fax:731-653-0053
Is Sole Proprietor?:No
Enumeration Date:2006-01-14
Last Update Date:2021-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNPA1170363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1530813Medicaid
TN1530813Medicaid
TNQ41756Medicare UPIN