Provider Demographics
NPI:1205895513
Name:CANNADA, LISA KAYE (MD)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:KAYE
Last Name:CANNADA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 370
Mailing Address - Street 2:
Mailing Address - City:FORTSON
Mailing Address - State:GA
Mailing Address - Zip Code:31808-0370
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:706-494-3008
Practice Address - Street 1:449 N WENDOVER RD STE A
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28211-1064
Practice Address - Country:US
Practice Address - Phone:704-316-6005
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-23
Last Update Date:2020-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2008025528207XX0801X
TXM1558207XX0801X
NC2020-00453207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
No207XX0801XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryOrthopaedic Trauma
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1205895513Medicaid
TX174517601Medicaid
TX174517601Medicaid
MO150410003Medicare PIN
TXCA08D7695Medicare ID - Type Unspecified