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General NPI Number Information
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NPI Number | 1962439745
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Entity Type | Individual
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Provider Name | LISA PETRONELLA SHOCK PA
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Gender | Female
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Dates
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Enumeration Date | 06/27/2006
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Last Update Date | 07/10/2025
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Provider Practice Location Address
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Address Line | 4909 GREEN RD
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City | RALEIGH
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State | NC
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Zip | 27616-3418
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Country | US
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Telephone | 919-790-0288
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Fax |
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Provider Business Mailing Address
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Address Line | 1929 KATELAND CT
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City | APEX
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State | NC
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Zip | 27502-6611
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Country | US
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Telephone | 919-593-1557
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number | 6237
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License Number State | TN
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Taxonomy #2
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number | 102885
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License Number State | NC
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