Provider Demographics
NPI:1831122357
Name:FARMER, LISA A (MD)
Entity Type:Individual
Prefix:DR
First Name:LISA
Middle Name:A
Last Name:FARMER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:LISA
Other - Middle Name:A
Other - Last Name:FARMER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:1157 FORSYTH ST
Mailing Address - Street 2:SUITE 200
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31201-7452
Mailing Address - Country:US
Mailing Address - Phone:478-743-4321
Mailing Address - Fax:478-330-6052
Practice Address - Street 1:1157 FORSYTH ST
Practice Address - Street 2:SUITE 200
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31201-7452
Practice Address - Country:US
Practice Address - Phone:478-743-4321
Practice Address - Fax:478-330-6052
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-08
Last Update Date:2015-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA040660174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000819442DMedicaid
GRP7545OtherMEDICARE GRP NUMBER
GAG98373Medicare UPIN
GA000819442DMedicaid