MEDICARE: MS. LISA SMITH VEALE BOONE PA-C

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	363A00000X	Physician Assistant	0010-09564	NC
2	363A00000X	Physician Assistant	C07519	MD
3	363A00000X	Physician Assistant	0110-006975	VA
4	363A00000X	Physician Assistant	PA03829	TX

General Provider Information

NPI Number	:	1427152479
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. LISA SMITH VEALE BOONE PA-C

Provider Business Mailing Address
First Line	:	215 RAINBOW DR # 11572
Second Line	:
City	:	LIVINGSTON
State	:	TX
Zip	:	77399-2015
Country	:	US
Telephone Number	:	210-355-0740
Fax Number	:

Provider Business Practice Location Address
First Line	:	2555 COURT DR STE 120
Second Line	:
City	:	GASTONIA
State	:	NC
Zip	:	28054-2177
Country	:	US
Telephone Number	:	704-834-3070
Fax Number	:

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

Provider Enumeration Date	:	09/12/2006
Last Update Date	:	04/14/2020

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