Provider Demographics
NPI:1821018219
Name:GROOMS, LISA ANNE (PA)
Entity Type:Individual
Prefix:MRS
First Name:LISA
Middle Name:ANNE
Last Name:GROOMS
Suffix:
Gender:F
Credentials:PA
Other - Prefix:MISS
Other - First Name:LISA
Other - Middle Name:ANNE
Other - Last Name:WESTLEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4532 PLANK RD
Mailing Address - Street 2:
Mailing Address - City:FREDERICKSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:22407-0139
Mailing Address - Country:US
Mailing Address - Phone:540-252-1840
Mailing Address - Fax:540-252-1841
Practice Address - Street 1:4532 PLANK RD
Practice Address - Street 2:
Practice Address - City:FREDERICKSBURG
Practice Address - State:VA
Practice Address - Zip Code:22407-0139
Practice Address - Country:US
Practice Address - Phone:540-252-1840
Practice Address - Fax:540-252-1841
Is Sole Proprietor?:No
Enumeration Date:2006-07-20
Last Update Date:2017-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110002015363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA540896390OtherTRICARE
VA1821018219Medicaid
VA1821018219Medicaid