Provider Demographics
NPI:1770691016
Name:MCDONALD, LISA L (FNP-C)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:L
Last Name:MCDONALD
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:L
Other - Last Name:MCDONALD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:FNP-C
Mailing Address - Street 1:16 ST EDMUNDS WAY
Mailing Address - Street 2:PO BOX 94
Mailing Address - City:ELLENBURG
Mailing Address - State:NY
Mailing Address - Zip Code:12933-9998
Mailing Address - Country:US
Mailing Address - Phone:518-594-3500
Mailing Address - Fax:518-594-3035
Practice Address - Street 1:16 ST EDMUNDS WAY
Practice Address - Street 2:
Practice Address - City:ELLENBURG
Practice Address - State:NY
Practice Address - Zip Code:12933-9998
Practice Address - Country:US
Practice Address - Phone:518-594-3500
Practice Address - Fax:518-594-3035
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-28
Last Update Date:2016-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY370412-1164X00000X
NYF331452-1363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No164X00000XNursing Service ProvidersLicensed Vocational Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
0510GOtherEMPIRE BC/BS
NY02218500Medicaid
S97230Medicare UPIN
DD0373Medicare PIN