Provider Demographics
NPI:1881652642
Name:PRENTISS, LISA C (PA)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:C
Last Name:PRENTISS
Suffix:
Gender:F
Credentials:PA
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Mailing Address - Street 1:301C US ROUTE ONE
Mailing Address - Street 2:
Mailing Address - City:SCARBOROUGH
Mailing Address - State:ME
Mailing Address - Zip Code:04074-9701
Mailing Address - Country:US
Mailing Address - Phone:207-396-8600
Mailing Address - Fax:207-396-8632
Practice Address - Street 1:22 BRAMHALL ST
Practice Address - Street 2:PAVILION 1203
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04102-7133
Practice Address - Country:US
Practice Address - Phone:207-662-4618
Practice Address - Fax:207-662-6254
Is Sole Proprietor?:No
Enumeration Date:2006-05-02
Last Update Date:2011-06-03
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Provider Licenses
StateLicense IDTaxonomies
MEPA430363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MER96329Medicare UPIN
MEAP0566Medicare PIN