Provider Demographics
NPI:1255070439
Name:MOORE, LISA TINGEN (NP)
Entity type:Individual
Prefix:MRS
First Name:LISA
Middle Name:TINGEN
Last Name:MOORE
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 1:4670 MERRIWEATHER RD
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27107-6430
Mailing Address - Country:US
Mailing Address - Phone:336-785-0174
Mailing Address - Fax:
Practice Address - Street 1:1695 KERNERSVILLE MEDICAL PARKWAY
Practice Address - Street 2:
Practice Address - City:KERNERSVILLE
Practice Address - State:NC
Practice Address - Zip Code:27284
Practice Address - Country:US
Practice Address - Phone:336-515-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-03
Last Update Date:2022-06-03
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NC5016303363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health