Basic Information
| Provider Information | |||||||||
| NPI: | 1720089873 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SHOCKLEY | ||||||||
| FirstName: | LISA | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1308 | ||||||||
| Address2: | |||||||||
| City: | KINGSPORT | ||||||||
| State: | TN | ||||||||
| PostalCode: | 376621308 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4232243460 | ||||||||
| FaxNumber: | 4232243465 | ||||||||
| Practice Location | |||||||||
| Address1: | 135 W RAVINE RD | ||||||||
| Address2: | STE 5B | ||||||||
| City: | KINGSPORT | ||||||||
| State: | TN | ||||||||
| PostalCode: | 376603847 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4232243460 | ||||||||
| FaxNumber: | 4232243465 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/10/2005 | ||||||||
| LastUpdateDate: | 06/26/2008 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | 22142 | TN | Y | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 031807 | 01 | ANTHEM BCBS | OTHER | 5736099 | 05 | VA | MEDICAID | 64911829 | 05 | KY | MEDICAID | 3045909 | 01 | BLUE SHIELD OF TN | OTHER | 3066975 | 05 | TN | MEDICAID | 00013859 | 01 | NHC CARE ADMINISTRATORS | OTHER | 100010226 | 01 | PHP TENNCARE | OTHER | 890575L | 05 | NC | MEDICAID | 050046532 | 01 | RAILROAD MEDICARE | OTHER | TN0100 | 01 | JOHN DEERE | OTHER |