Basic Information
| Provider Information | |||||||||
| NPI: | 1124260930 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MCELLIGOTT | ||||||||
| FirstName: | LISA | ||||||||
| MiddleName: | N | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 746654 | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303746654 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9042022092 | ||||||||
| FaxNumber: | 9043937603 | ||||||||
| Practice Location | |||||||||
| Address1: | 1301 PALM AVE | ||||||||
| Address2: | |||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322078432 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9042027300 | ||||||||
| FaxNumber: | 9042027433 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/26/2009 | ||||||||
| LastUpdateDate: | 04/25/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 04/25/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | 002222 | CT | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical | 363A00000X | PA9115887 | FL | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 9046450 | 01 | CT | AETNA | OTHER | 020222 | 01 | CT | CONNECTICARE | OTHER | P00964332 | 01 | CT | RR MEDICARE | OTHER | 30-62086 | 01 | CT | AMERICHOICE | OTHER | 3V2970 | 01 | CT | HEALTHNET/COMMERCIAL | OTHER | 523682 | 01 | CT | WELLCARE | OTHER | 290002222CT01 | 01 | CT | ANTHEM BCBS CT | OTHER |