Provider Demographics
NPI:1316977234
Name:KERICH, LISA ANN (PA)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:ANN
Last Name:KERICH
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5204 COLLEYVILLE BOULEVARD
Mailing Address - Street 2:
Mailing Address - City:COLLEYVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:76034
Mailing Address - Country:US
Mailing Address - Phone:817-369-3300
Mailing Address - Fax:817-581-6127
Practice Address - Street 1:5204 COLLEYVILLE BOULEVARD
Practice Address - Street 2:
Practice Address - City:COLLEYVILLE
Practice Address - State:TX
Practice Address - Zip Code:76034
Practice Address - Country:US
Practice Address - Phone:817-369-3300
Practice Address - Fax:817-581-6127
Is Sole Proprietor?:No
Enumeration Date:2006-07-04
Last Update Date:2018-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA00181363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1023145OtherNCCPA
TX803N51OtherBCBS
TX205392801Medicaid
TXP00956844OtherRAILROAD
TX205392801Medicaid