Provider Demographics
NPI:1194960955
Name:LIPSCOMB, DEANNA MARIE (RPA-C)
Entity type:Individual
Prefix:MS
First Name:DEANNA
Middle Name:MARIE
Last Name:LIPSCOMB
Suffix:
Gender:F
Credentials:RPA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 PEPSI COLA DR
Mailing Address - Street 2:JHU HEALTH AND WELLNESS CENTER
Mailing Address - City:LATHAM
Mailing Address - State:NY
Mailing Address - Zip Code:12110-2306
Mailing Address - Country:US
Mailing Address - Phone:518-782-2479
Mailing Address - Fax:
Practice Address - Street 1:1 PEPSI COLA DR
Practice Address - Street 2:JHU HEALTH AND WELLNESS CENTER
Practice Address - City:LATHAM
Practice Address - State:NY
Practice Address - Zip Code:12110-2306
Practice Address - Country:US
Practice Address - Phone:518-782-2479
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-12-09
Last Update Date:2016-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY012912363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03524747Medicaid
NY03524747Medicaid