Provider Demographics
NPI:1104899301
Name:FEDORA, LISA ANN (CRNP)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:ANN
Last Name:FEDORA
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1671 CROOKED OAK DR
Mailing Address - Street 2:
Mailing Address - City:LANCASTER
Mailing Address - State:PA
Mailing Address - Zip Code:17601-4269
Mailing Address - Country:US
Mailing Address - Phone:717-569-5331
Mailing Address - Fax:717-569-5331
Practice Address - Street 1:1671 CROOKED OAK DR
Practice Address - Street 2:
Practice Address - City:LANCASTER
Practice Address - State:PA
Practice Address - Zip Code:17601-4269
Practice Address - Country:US
Practice Address - Phone:717-569-5331
Practice Address - Fax:717-569-5331
Is Sole Proprietor?:No
Enumeration Date:2006-02-08
Last Update Date:2012-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASP008664363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
Q61630Medicare UPIN
097493R3PMedicare ID - Type Unspecified