Provider Demographics
NPI:1588688345
Name:RADEBAUGH, LISA CARROLL (NP)
Entity type:Individual
Prefix:MS
First Name:LISA
Middle Name:CARROLL
Last Name:RADEBAUGH
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:40 TUDOR CT
Mailing Address - Street 2:
Mailing Address - City:LUTHERVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:21093-2967
Mailing Address - Country:US
Mailing Address - Phone:410-308-4822
Mailing Address - Fax:
Practice Address - Street 1:10753 FALLS RD PAVILION II
Practice Address - Street 2:SUITE 415
Practice Address - City:LUTHERVILLE
Practice Address - State:MD
Practice Address - Zip Code:21093-2967
Practice Address - Country:US
Practice Address - Phone:410-583-2970
Practice Address - Fax:410-583-2980
Is Sole Proprietor?:No
Enumeration Date:2006-07-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR080294363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD53410801OtherBLUE SHIELD
MD972003100Medicaid
MD242566OtherKAISER
MD0092OtherCAREFIRST REGIONAL
MDH996Medicare ID - Type Unspecified
MD972003100Medicaid
MD242566OtherKAISER