Provider Demographics
NPI:1386601441
Name:CARLSON, LISA C (MD)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:C
Last Name:CARLSON
Suffix:
Gender:F
Credentials:MD
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 858
Mailing Address - Street 2:MC A410
Mailing Address - City:HERSHEY
Mailing Address - State:PA
Mailing Address - Zip Code:17033-0858
Mailing Address - Country:US
Mailing Address - Phone:800-243-1455
Mailing Address - Fax:
Practice Address - Street 1:1 CONTINENTAL DR
Practice Address - Street 2:
Practice Address - City:ELIZABETHTOWN
Practice Address - State:PA
Practice Address - Zip Code:17022-2231
Practice Address - Country:US
Practice Address - Phone:717-361-0666
Practice Address - Fax:717-361-0202
Is Sole Proprietor?:No
Enumeration Date:2006-05-01
Last Update Date:2018-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD068946L208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0017580860001Medicaid
G96479Medicare UPIN