Provider Demographics
NPI:1124260930
Name:MCELLIGOTT, LISA N (PA-C)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:N
Last Name:MCELLIGOTT
Suffix:
Gender:
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 746654
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-6654
Mailing Address - Country:US
Mailing Address - Phone:904-202-2092
Mailing Address - Fax:904-376-4075
Practice Address - Street 1:1301 PALM AVE STE 700
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32207-8457
Practice Address - Country:US
Practice Address - Phone:904-202-7300
Practice Address - Fax:904-202-2754
Is Sole Proprietor?:No
Enumeration Date:2009-03-26
Last Update Date:2025-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT002222363AM0700X
FLPA9115887363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT3V2970OtherHEALTHNET/COMMERCIAL
CT523682OtherWELLCARE
CTP00964332OtherRR MEDICARE
CT30-62086OtherAMERICHOICE
CT9046450OtherAETNA
CT290002222CT01OtherANTHEM BCBS CT
CT020222OtherCONNECTICARE
CT3V2970OtherHEALTHNET/COMMERCIAL