Provider Demographics
NPI:1720155476
Name:DOVE, LISA DIANNE
Entity Type:Individual
Prefix:MS
First Name:LISA
Middle Name:DIANNE
Last Name:DOVE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:619 19TH ST S
Mailing Address - Street 2:P 915
Mailing Address - City:BIRMINGHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35233-1900
Mailing Address - Country:US
Mailing Address - Phone:205-975-0512
Mailing Address - Fax:205-975-6404
Practice Address - Street 1:619 19TH ST S
Practice Address - Street 2:P 915
Practice Address - City:BIRMINGHAM
Practice Address - State:AL
Practice Address - Zip Code:35233-1900
Practice Address - Country:US
Practice Address - Phone:205-975-0512
Practice Address - Fax:205-975-6404
Is Sole Proprietor?:No
Enumeration Date:2006-11-29
Last Update Date:2013-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALPA491363AS0400X
AL491363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ALPAYEE #529916450Medicaid
AL009943016Medicaid
AL009943016Medicaid