Provider Demographics
NPI:1366516015
Name:MARSHALL, LISA GAYLE (MD)
Entity type:Individual
Prefix:DR
First Name:LISA
Middle Name:GAYLE
Last Name:MARSHALL
Suffix:
Gender:F
Credentials:MD
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Mailing Address - Street 1:123 PROFESSIONAL PARK DR
Mailing Address - Street 2:101
Mailing Address - City:MOORESVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28117
Mailing Address - Country:US
Mailing Address - Phone:704-662-7081
Mailing Address - Fax:704-663-5693
Practice Address - Street 1:123 PROFESSIONAL PARK DR
Practice Address - Street 2:101
Practice Address - City:MOORESVILLE
Practice Address - State:NC
Practice Address - Zip Code:28117
Practice Address - Country:US
Practice Address - Phone:704-662-7081
Practice Address - Fax:704-663-5693
Is Sole Proprietor?:No
Enumeration Date:2006-11-17
Last Update Date:2023-03-07
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
NC29771208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8954098Medicaid
NC29771OtherNC LICENSE
NCBM0250275OtherDEA
NC8954098Medicaid