Basic Information
| Provider Information | |||||||||
| NPI: | 1134448269 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WEBSTER-LAKE | ||||||||
| FirstName: | CARISSA | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1000, DEPT 457 | ||||||||
| Address2: | |||||||||
| City: | MEMPHIS | ||||||||
| State: | TN | ||||||||
| PostalCode: | 381480001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9012753662 | ||||||||
| FaxNumber: | 9012710155 | ||||||||
| Practice Location | |||||||||
| Address1: | 1325 EASTMORELAND AVE STE 310 | ||||||||
| Address2: | |||||||||
| City: | MEMPHIS | ||||||||
| State: | TN | ||||||||
| PostalCode: | 381047544 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9012726010 | ||||||||
| FaxNumber: | 9012666468 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/28/2010 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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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 | 208600000X | 54698 | CT | N | Allopathic & Osteopathic Physicians | Surgery | 2086S0129X | 54698 | CT | N | Allopathic & Osteopathic Physicians | Surgery | Vascular Surgery | 2086S0129X | 59921 | TN | Y | Allopathic & Osteopathic Physicians | Surgery | Vascular Surgery |
No ID Information.