Provider Demographics
NPI:1770575219
Name:MUCCIOLO, LISA ANNE (MD)
Entity type:Individual
Prefix:DR
First Name:LISA
Middle Name:ANNE
Last Name:MUCCIOLO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:MS
Other - First Name:LISA
Other - Middle Name:ANNE
Other - Last Name:LICATA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:1 HOSPITAL DR STE 306
Mailing Address - Street 2:
Mailing Address - City:LEWISBURG
Mailing Address - State:PA
Mailing Address - Zip Code:17837-9350
Mailing Address - Country:US
Mailing Address - Phone:570-522-4110
Mailing Address - Fax:570-768-3911
Practice Address - Street 1:80 MEDICAL PARK DR
Practice Address - Street 2:
Practice Address - City:LEWISBURG
Practice Address - State:PA
Practice Address - Zip Code:17837-6343
Practice Address - Country:US
Practice Address - Phone:570-768-4646
Practice Address - Fax:570-768-4648
Is Sole Proprietor?:No
Enumeration Date:2005-08-19
Last Update Date:2022-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD067434L207RR0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0017494250005Medicaid
PA026742NYFMedicare PIN
G91808Medicare UPIN