Provider Demographics
NPI:1891394235
Name:POPOVICH, LISA ANN (AGNP -BC)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:ANN
Last Name:POPOVICH
Suffix:
Gender:F
Credentials:AGNP -BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5038 COMMON GOOD LN
Mailing Address - Street 2:
Mailing Address - City:DUBLIN
Mailing Address - State:OH
Mailing Address - Zip Code:43016-9700
Mailing Address - Country:US
Mailing Address - Phone:614-214-4223
Mailing Address - Fax:
Practice Address - Street 1:3703 CANON RIDGE PL
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43230-4010
Practice Address - Country:US
Practice Address - Phone:614-214-4223
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-17
Last Update Date:2020-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH419374363LA2200X
OH0027812363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health