Provider Demographics
NPI:1801909874
Name:HEBERT, LISA G (PA)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:G
Last Name:HEBERT
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 S COLLEGE ST
Mailing Address - Street 2:SUITE 500
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28202-2005
Mailing Address - Country:US
Mailing Address - Phone:704-632-4022
Mailing Address - Fax:704-632-4001
Practice Address - Street 1:200 S COLLEGE ST
Practice Address - Street 2:SUITE 500
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28202-2005
Practice Address - Country:US
Practice Address - Phone:704-632-4022
Practice Address - Fax:704-632-4001
Is Sole Proprietor?:No
Enumeration Date:2006-08-16
Last Update Date:2015-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC102034363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1801909874Medicaid
NCS76004Medicare UPIN
NC2752997FMedicare PIN
NC2752997OMedicare PIN
NC2750090AMedicare PIN
NC1801909874Medicaid
NC2752997DMedicare PIN
NC2752997NMedicare PIN
NC2752997LMedicare PIN
NC2752997BMedicare PIN