Provider Demographics
NPI:1932552890
Name:PARKER, LISA MARIE (NP)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:MARIE
Last Name:PARKER
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 HICKMAN ST
Mailing Address - Street 2:
Mailing Address - City:GRANITEVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29829-2955
Mailing Address - Country:US
Mailing Address - Phone:803-392-7092
Mailing Address - Fax:803-392-7174
Practice Address - Street 1:1321A INTERSTATE PKWY
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30909-5626
Practice Address - Country:US
Practice Address - Phone:706-738-7246
Practice Address - Fax:706-738-7248
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-15
Last Update Date:2020-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN201619363LF0000X
SC20218363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP8328Medicaid