MEDICARE: LISA MERCADO 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	0147471	NY
2	363A00000X	Physician Assistant	5988	SC

General Provider Information

NPI Number	:	1467749556
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LISA MERCADO PA-C

Provider Business Mailing Address
First Line	:	170 VILLAGE CENTER BLVD
Second Line	:
City	:	MYRTLE BEACH
State	:	SC
Zip	:	29579-6618
Country	:	US
Telephone Number	:	843-449-5848
Fax Number	:	843-692-0908

Provider Business Practice Location Address
First Line	:	170 VILLAGE CENTER BLVD
Second Line	:
City	:	MYRTLE BEACH
State	:	SC
Zip	:	29579-6618
Country	:	US
Telephone Number	:	843-449-5848
Fax Number	:	843-692-0908

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

Provider Enumeration Date	:	07/08/2011
Last Update Date	:	03/28/2026

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Directions to “ LISA MERCADO PA-C” Practice Location

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