1083620512 NPI number — LISA M NOBLES PA

Table of content: LISA M NOBLES PA (NPI 1083620512)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1083620512 NPI number — LISA M NOBLES PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
NOBLES
Provider First Name:
LISA
Provider Middle Name:
M
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PA
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1083620512
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/15/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
100 KINGS HWY S
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ROCHESTER
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
14617-5504
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
585-922-1900
Provider Business Mailing Address Fax Number:
585-922-0636

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
125 RED CREEK DR
Provider Second Line Business Practice Location Address:
SUITE 205
Provider Business Practice Location Address City Name:
ROCHESTER
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
14623-4272
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
585-321-0340
Provider Business Practice Location Address Fax Number:
585-334-6373
Provider Enumeration Date:
08/01/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363AM0700X , with the licence number:  003157 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 03209294 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".




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