Basic Information
| Provider Information | |||||||||
| NPI: | 1710966692 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ROBERTSON | ||||||||
| FirstName: | LISA | ||||||||
| MiddleName: | E | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 790 NORTHERN BLVD | ||||||||
| Address2: | SUITE K | ||||||||
| City: | SOUTH ABINGTON TOWNSHIP | ||||||||
| State: | PA | ||||||||
| PostalCode: | 184118799 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5705864141 | ||||||||
| FaxNumber: | 5705866722 | ||||||||
| Practice Location | |||||||||
| Address1: | 790 NORTHERN BLVD | ||||||||
| Address2: | SUITE K | ||||||||
| City: | SOUTH ABINGTON TOWNSHIP | ||||||||
| State: | PA | ||||||||
| PostalCode: | 184118799 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5705864141 | ||||||||
| FaxNumber: | 5705866722 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/10/2006 | ||||||||
| LastUpdateDate: | 02/07/2011 | ||||||||
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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 | 207Q00000X | OS008274L | PA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 001532070 | 05 | PA | MEDICAID |