Provider Demographics
NPI:1760621502
Name:HARLEY, LISA TAMARA (PA)
Entity Type:Individual
Prefix:MRS
First Name:LISA
Middle Name:TAMARA
Last Name:HARLEY
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 1:60 COMMERCE PLAZA CIR
Mailing Address - Street 2:
Mailing Address - City:PEMBROKE
Mailing Address - State:NC
Mailing Address - Zip Code:28372-7386
Mailing Address - Country:US
Mailing Address - Phone:910-521-2900
Mailing Address - Fax:910-775-9165
Practice Address - Street 1:95 LEONARD AVE
Practice Address - Street 2:BUILDING 1, SUITE 202
Practice Address - City:WASHINGTON
Practice Address - State:PA
Practice Address - Zip Code:15301-3368
Practice Address - Country:US
Practice Address - Phone:724-206-0610
Practice Address - Fax:724-503-4156
Is Sole Proprietor?:No
Enumeration Date:2009-02-18
Last Update Date:2017-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-01739363AM0700X
363A00000X
IN9904821A.363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
INM400056885Medicare PIN
IN000000735539OtherANTHEM
INM400056884Medicare PIN