Provider Demographics
NPI:1790828077
Name:COOK, LISA ANN (PAC)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:ANN
Last Name:COOK
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:ANN
Other - Last Name:HILL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PAC
Mailing Address - Street 1:PO BOX 17334
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21297-1334
Mailing Address - Country:US
Mailing Address - Phone:703-723-7337
Mailing Address - Fax:703-723-6848
Practice Address - Street 1:19500 SANDRIDGE WAY
Practice Address - Street 2:SUITE 110
Practice Address - City:LEESBURG
Practice Address - State:VA
Practice Address - Zip Code:20176-3688
Practice Address - Country:US
Practice Address - Phone:703-723-7337
Practice Address - Fax:703-723-6848
Is Sole Proprietor?:No
Enumeration Date:2007-02-15
Last Update Date:2010-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110002738363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant