Provider Demographics
NPI:1699430637
Name:KIRK, LISA THOMPSON (PA-C)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:THOMPSON
Last Name:KIRK
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 1:7585 CLARINGTON CV
Mailing Address - Street 2:
Mailing Address - City:SOUTHAVEN
Mailing Address - State:MS
Mailing Address - Zip Code:38671-5656
Mailing Address - Country:US
Mailing Address - Phone:662-349-0200
Mailing Address - Fax:662-349-1666
Practice Address - Street 1:7585 CLARINGTON CV
Practice Address - Street 2:
Practice Address - City:SOUTHAVEN
Practice Address - State:MS
Practice Address - Zip Code:38671-5656
Practice Address - Country:US
Practice Address - Phone:662-349-0200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-04
Last Update Date:2024-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSPA00615363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant