Provider Demographics
NPI:1457774028
Name:GENNOSA, LISA (PA-C)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:GENNOSA
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 1:504 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:ROBERSONVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27871-9567
Mailing Address - Country:US
Mailing Address - Phone:252-795-5555
Mailing Address - Fax:252-795-5566
Practice Address - Street 1:504 N MAIN ST
Practice Address - Street 2:
Practice Address - City:ROBERSONVILLE
Practice Address - State:NC
Practice Address - Zip Code:27871-9567
Practice Address - Country:US
Practice Address - Phone:252-795-5555
Practice Address - Fax:252-795-5566
Is Sole Proprietor?:Yes
Enumeration Date:2014-02-01
Last Update Date:2014-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-04811363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant