Provider Demographics
NPI:1417993205
Name:QUARLES, LISA M (PA)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:M
Last Name:QUARLES
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5236 KINGSBROOK DRIVE
Mailing Address - Street 2:
Mailing Address - City:FREDERICK
Mailing Address - State:MD
Mailing Address - Zip Code:21703
Mailing Address - Country:US
Mailing Address - Phone:301-696-1389
Mailing Address - Fax:
Practice Address - Street 1:5401 OLD COURT ROAD
Practice Address - Street 2:NORTHWEST HOSPITAL
Practice Address - City:RANDALLSTOWN
Practice Address - State:MD
Practice Address - Zip Code:21133
Practice Address - Country:US
Practice Address - Phone:410-521-5950
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-21
Last Update Date:2013-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC0002523363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
Q24589Medicare UPIN
MD568LM927Medicare ID - Type Unspecified