Provider Demographics
NPI:1124323803
Name:LISA M BOOKERT M.D. PA.
Entity type:Organization
Organization Name:LISA M BOOKERT M.D. PA.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:LISA
Authorized Official - Middle Name:M
Authorized Official - Last Name:BOOKERT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:919-553-6060
Mailing Address - Street 1:900 S LOMBARD ST
Mailing Address - Street 2:
Mailing Address - City:CLAYTON
Mailing Address - State:NC
Mailing Address - Zip Code:27520-2737
Mailing Address - Country:US
Mailing Address - Phone:919-553-6060
Mailing Address - Fax:919-553-4747
Practice Address - Street 1:900 S LOMBARD ST
Practice Address - Street 2:
Practice Address - City:CLAYTON
Practice Address - State:NC
Practice Address - Zip Code:27520-2737
Practice Address - Country:US
Practice Address - Phone:919-553-6060
Practice Address - Fax:919-553-4747
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-01-11
Last Update Date:2011-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC30780261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8916757Medicaid
NC2203906Medicare PIN
NCA49195Medicare UPIN