Provider Demographics
NPI:1215998927
Name:CLARK, LISA MARIE (CAA)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:MARIE
Last Name:CLARK
Suffix:
Gender:F
Credentials:CAA
Other - Prefix:MS
Other - First Name:LISA
Other - Middle Name:MARIE
Other - Last Name:JULIAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CAA
Mailing Address - Street 1:11100 EUCLID AVE
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44106-1716
Mailing Address - Country:US
Mailing Address - Phone:216-844-5583
Mailing Address - Fax:
Practice Address - Street 1:11100 EUCLID AVE
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44106-1716
Practice Address - Country:US
Practice Address - Phone:216-844-5583
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-31
Last Update Date:2024-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN75000044A367H00000X
NC1000-00543367H00000X
OH67000102367H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367H00000XPhysician Assistants & Advanced Practice Nursing ProvidersAnesthesiologist Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000001295036OtherANTHEM PTAN
NC1215998927Medicaid
NC1215998927OtherTRICARE
NC185M9OtherBCBS
IN1102450646OtherANTHEM PTAN
OH377459OtherANTHEM BCBS
OH2438348Medicaid