Provider Demographics
NPI:1427152479
Name:BOONE, LISA SMITH VEALE (PA-C)
Entity type:Individual
Prefix:MS
First Name:LISA
Middle Name:SMITH VEALE
Last Name:BOONE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:SMITH
Other - Last Name:VEALE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:215 RAINBOW DR # 11572
Mailing Address - Street 2:
Mailing Address - City:LIVINGSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77399-2015
Mailing Address - Country:US
Mailing Address - Phone:210-355-0740
Mailing Address - Fax:
Practice Address - Street 1:2555 COURT DR STE 120
Practice Address - Street 2:
Practice Address - City:GASTONIA
Practice Address - State:NC
Practice Address - Zip Code:28054-2177
Practice Address - Country:US
Practice Address - Phone:704-834-3070
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-12
Last Update Date:2020-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-09564363A00000X
MDC07519363A00000X
VA0110-006975363A00000X
TXPA03829363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXTXB116705Medicare UPIN