Provider Demographics
NPI:1548338353
Name:LEMLEY GIBSON, LISA D (PA)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:D
Last Name:LEMLEY GIBSON
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:D
Other - Last Name:LEMLEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:10475 CENTURION PKWY N STE 201
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32256-5004
Mailing Address - Country:US
Mailing Address - Phone:904-223-3321
Mailing Address - Fax:904-223-2169
Practice Address - Street 1:1699 S 14TH ST STE 16
Practice Address - Street 2:
Practice Address - City:FERNANDINA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32034-1965
Practice Address - Country:US
Practice Address - Phone:904-223-3321
Practice Address - Fax:904-223-2169
Is Sole Proprietor?:No
Enumeration Date:2006-12-01
Last Update Date:2021-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYPA1116363A00000X
OH50.002146RX363A00000X
FLPA9113789363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0146148Medicaid
KY7100063860Medicaid
KYP00688242OtherRR MEDICARE
KY000000593569OtherANTHEM BCBS