Provider Demographics
NPI:1457378085
Name:REPKO, LISA M (PA-C)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:M
Last Name:REPKO
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:250 N SHADELAND AVE
Mailing Address - Street 2:SUITE 130- PROVIDER ENROLLMENT
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46219-4959
Mailing Address - Country:US
Mailing Address - Phone:866-916-5259
Mailing Address - Fax:231-922-4030
Practice Address - Street 1:1606 N 7TH ST.
Practice Address - Street 2:
Practice Address - City:TERRE HAUTE
Practice Address - State:IN
Practice Address - Zip Code:47804-2706
Practice Address - Country:US
Practice Address - Phone:217-443-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2017-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601003446363A00000X
IL085-002189363A00000X
IN10001476A363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL208064Medicare PIN
ILK03048Medicare PIN
P35855Medicare UPIN