Provider Demographics
NPI:1528056660
Name:PLOCK, LISA M (NP)
Entity type:Individual
Prefix:MRS
First Name:LISA
Middle Name:M
Last Name:PLOCK
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:PO BOX 1038
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:GA
Mailing Address - Zip Code:31902-1038
Mailing Address - Country:US
Mailing Address - Phone:706-660-6148
Mailing Address - Fax:706-660-2843
Practice Address - Street 1:2000 10TH AVE
Practice Address - Street 2:SUITE 200
Practice Address - City:COLUMBUS
Practice Address - State:GA
Practice Address - Zip Code:31901-3700
Practice Address - Country:US
Practice Address - Phone:706-321-3745
Practice Address - Fax:706-321-3749
Is Sole Proprietor?:No
Enumeration Date:2005-10-12
Last Update Date:2014-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN075180363LF0000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000806649EMedicaid
581719867066OtherTRICARE
581719867066OtherTRICARE