Provider Demographics
NPI:1457533283
Name:CONWAY, LISA MARIE (PA-C)
Entity Type:Individual
Prefix:MS
First Name:LISA
Middle Name:MARIE
Last Name:CONWAY
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 1:2716 OLD ROSEBUD RD
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40509-8008
Mailing Address - Country:US
Mailing Address - Phone:859-543-1577
Mailing Address - Fax:
Practice Address - Street 1:2716 OLD ROSEBUD RD
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40509-8008
Practice Address - Country:US
Practice Address - Phone:859-543-1577
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-12-04
Last Update Date:2020-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH50.002674363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH50.002674OtherOH LICENSE
KY7100036940Medicaid
KYPA1092OtherLICENSE
1349111Medicare PIN