Provider Demographics
NPI:1922033653
Name:HOGAN, LISA (NP)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:HOGAN
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15 ROOSEVELT WALK
Mailing Address - Street 2:
Mailing Address - City:BREEZY POINT
Mailing Address - State:NY
Mailing Address - Zip Code:11697
Mailing Address - Country:US
Mailing Address - Phone:718-474-7961
Mailing Address - Fax:
Practice Address - Street 1:1468 MADISON AVE
Practice Address - Street 2:ONE GUSTAV LEVY PLACE
Practice Address - City:MANHATTAN
Practice Address - State:NY
Practice Address - Zip Code:10029
Practice Address - Country:US
Practice Address - Phone:212-241-8095
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-11
Last Update Date:2023-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF332792363LF0000X
NY508543207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02225372Medicaid
NYA400005776Medicare PIN