Provider Demographics
NPI:1457374639
Name:CAMPENELLA, LISA MARIE (PA-C)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:MARIE
Last Name:CAMPENELLA
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25 JOHN JAMES AUDUBON WAY
Mailing Address - Street 2:
Mailing Address - City:MARLTON
Mailing Address - State:NJ
Mailing Address - Zip Code:08053-7219
Mailing Address - Country:US
Mailing Address - Phone:856-701-4485
Mailing Address - Fax:
Practice Address - Street 1:25 JOHN JAMES AUDUBON WAY STE 410
Practice Address - Street 2:
Practice Address - City:MARLTON
Practice Address - State:NJ
Practice Address - Zip Code:08053-7219
Practice Address - Country:US
Practice Address - Phone:856-701-4485
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-26
Last Update Date:2023-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA051861363AS0400X
NJ25MP00132100363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
Q50904Medicare UPIN
NJ094142Medicare PIN