Provider Demographics
NPI:1780608729
Name:KEETON, LISA (MD)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:KEETON
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 936857
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:31193-6857
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2131 S 17TH ST
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28401-7407
Practice Address - Country:US
Practice Address - Phone:910-343-2606
Practice Address - Fax:910-815-5698
Is Sole Proprietor?:No
Enumeration Date:2006-07-26
Last Update Date:2021-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC200000847208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCQ0084IMedicaid
NC1780608729Medicaid
NC891271KMedicaid
NC2280537BMedicare PIN
NC1780608729Medicaid
NC2280537CMedicare PIN
H18910Medicare UPIN