MEDICARE: LISA PROCTOR NP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LA2100X	Acute Care Nurse Practitioner	F430338	NY

General Provider Information

NPI Number	:	1114143419
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LISA PROCTOR NP

Provider Business Mailing Address
First Line	:	110 VANWOERT RD
Second Line	:
City	:	SPENCER
State	:	NY
Zip	:	14883-9721
Country	:	US
Telephone Number	:	607-589-6826
Fax Number	:

Provider Business Practice Location Address
First Line	:	310 TAUGHANNOCK BLVD
Second Line	:
City	:	ITHACA
State	:	NY
Zip	:	14850-3251
Country	:	US
Telephone Number	:	607-252-3590
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/17/2007
Last Update Date	:	02/21/2011

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