Provider Demographics
NPI:1336179134
Name:KNUST, LISA MARIE (MD)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:MARIE
Last Name:KNUST
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 1:856 J CLYDE MORRIS BLVD
Mailing Address - Street 2:SUITE A
Mailing Address - City:NEWPORT NEWS
Mailing Address - State:VA
Mailing Address - Zip Code:23601-1318
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:13478 CARROLLTON BLVD
Practice Address - Street 2:UNITS D & E
Practice Address - City:CARROLLTON
Practice Address - State:VA
Practice Address - Zip Code:23314-3206
Practice Address - Country:US
Practice Address - Phone:757-238-7043
Practice Address - Fax:757-238-7052
Is Sole Proprietor?:No
Enumeration Date:2006-07-04
Last Update Date:2014-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101238467207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA015949R53Medicare PIN
VA1336179134Medicaid
VAP00611383Medicare PIN