Provider Demographics
NPI:1962439745
Name:SHOCK, LISA PETRONELLA (PA)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:PETRONELLA
Last Name:SHOCK
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 1:1929 KATELAND CT
Mailing Address - Street 2:
Mailing Address - City:APEX
Mailing Address - State:NC
Mailing Address - Zip Code:27502-6611
Mailing Address - Country:US
Mailing Address - Phone:919-593-1557
Mailing Address - Fax:
Practice Address - Street 1:4909 GREEN RD
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27616-3418
Practice Address - Country:US
Practice Address - Phone:919-790-0288
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-27
Last Update Date:2024-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC102885363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCS87186Medicare UPIN
NC2752510DMedicare ID - Type UnspecifiedMEDICARE INDIV