Provider Demographics
NPI:1205098811
Name:BLACK, LISA M (PA)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:M
Last Name:BLACK
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:
Other - Last Name:BLOM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:617 RIVERSIDE AVE
Mailing Address - Street 2:
Mailing Address - City:BURLINGTON
Mailing Address - State:VT
Mailing Address - Zip Code:05401-1601
Mailing Address - Country:US
Mailing Address - Phone:802-864-6309
Mailing Address - Fax:802-860-4313
Practice Address - Street 1:111 COLCHESTER AVE
Practice Address - Street 2:UVM MEDICAL CENTER EMERGENCY DEPARTMENT
Practice Address - City:BURLINGTON
Practice Address - State:VT
Practice Address - Zip Code:05401-1473
Practice Address - Country:US
Practice Address - Phone:802-847-0000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-06-26
Last Update Date:2017-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT055.0031258363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant