1205807500 NPI number — MRS. LISA WAGGONER BARKER M.D.

Table of content: (NPI 1619294170)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1205807500 NPI number — MRS. LISA WAGGONER BARKER M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BARKER
Provider First Name:
LISA
Provider Middle Name:
WAGGONER
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
MCCOY
Provider Other First Name:
LISA
Provider Other Middle Name:
WAGGONER
Provider Other Name Prefix Text:
MRS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
M.D.
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1205807500
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/17/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2061 COLLIER PKWY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LAND O LAKES
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
34639-5202
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
727-845-5707
Provider Business Mailing Address Fax Number:
813-501-8250

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2061 COLLIER PKWY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LAND O LAKES
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
34639-5202
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
727-845-5707
Provider Business Practice Location Address Fax Number:
813-501-8250
Provider Enumeration Date:
01/27/2006

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: 207Q00000X , with the licence number:  30616 , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2086H0002X , with the licence number: ME128980 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 000000045747 . This is a "BLUE CROSS AND BLUE SHIELD" identifier . This identifiers is of the category "OTHER".
  • Identifier: 000000583695 . This is a "BLUE CROSS AND BLUE SHIELD" identifier . This identifiers is of the category "OTHER".
  • Identifier: 64306160 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 023801800 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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