Provider Demographics
NPI:1720089873
Name:SHOCKLEY, LISA L (MD)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:L
Last Name:SHOCKLEY
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:PO BOX 1308
Mailing Address - Street 2:
Mailing Address - City:KINGSPORT
Mailing Address - State:TN
Mailing Address - Zip Code:37662-1308
Mailing Address - Country:US
Mailing Address - Phone:423-224-3460
Mailing Address - Fax:423-224-3465
Practice Address - Street 1:135 W RAVINE RD
Practice Address - Street 2:STE 5B
Practice Address - City:KINGSPORT
Practice Address - State:TN
Practice Address - Zip Code:37660-3847
Practice Address - Country:US
Practice Address - Phone:423-224-3460
Practice Address - Fax:423-224-3465
Is Sole Proprietor?:No
Enumeration Date:2005-08-10
Last Update Date:2008-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN22142207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
031807OtherANTHEM BCBS
VA5736099Medicaid
KY64911829Medicaid
3045909OtherBLUE SHIELD OF TN
TN3066975Medicaid
00013859OtherNHC CARE ADMINISTRATORS
100010226OtherPHP TENNCARE
NC890575LMedicaid
050046532OtherRAILROAD MEDICARE
TN0100OtherJOHN DEERE
NC890575LMedicaid
TN3066976Medicare PIN