Provider Demographics
NPI:1619083102
Name:BOGET, LISA A (PA-C)
Entity type:Individual
Prefix:MRS
First Name:LISA
Middle Name:A
Last Name:BOGET
Suffix:
Gender:
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 1:4948 BENCHMARK CENTRE DR
Mailing Address - Street 2:
Mailing Address - City:SWANSEA
Mailing Address - State:IL
Mailing Address - Zip Code:62226-2027
Mailing Address - Country:US
Mailing Address - Phone:618-628-2588
Mailing Address - Fax:618-628-1363
Practice Address - Street 1:4948 BENCHMARK CENTRE DR
Practice Address - Street 2:
Practice Address - City:SWANSEA
Practice Address - State:IL
Practice Address - Zip Code:62226-2027
Practice Address - Country:US
Practice Address - Phone:618-628-2588
Practice Address - Fax:618-628-1363
Is Sole Proprietor?:No
Enumeration Date:2006-08-21
Last Update Date:2025-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYPA752363AM0700X
IL085000996363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1619083102Medicaid
KYP00080693OtherRAILROAD MEDICARE
KY000000324636OtherANTHEM
KYP00080693OtherRAILROAD MEDICARE
KYS49488Medicare UPIN