Provider Demographics
NPI:1396714242
Name:HOGAN-MOODY, LISABETH D (PA-C)
Entity type:Individual
Prefix:
First Name:LISABETH
Middle Name:D
Last Name:HOGAN-MOODY
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2800 E BROAD ST
Mailing Address - Street 2:SUITE 124
Mailing Address - City:MANSFIELD
Mailing Address - State:TX
Mailing Address - Zip Code:76063-6409
Mailing Address - Country:US
Mailing Address - Phone:817-539-0959
Mailing Address - Fax:817-539-0480
Practice Address - Street 1:2800 E BROAD ST
Practice Address - Street 2:SUITE 124
Practice Address - City:MANSFIELD
Practice Address - State:TX
Practice Address - Zip Code:76063-6409
Practice Address - Country:US
Practice Address - Phone:817-539-0959
Practice Address - Fax:817-539-0480
Is Sole Proprietor?:No
Enumeration Date:2006-03-14
Last Update Date:2014-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA02623363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXP00241Medicare UPIN
TX83N734Medicare ID - Type Unspecified