Provider Demographics
NPI:1043598485
Name:TOLLIVER, LISA MARIE (PA-C)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:MARIE
Last Name:TOLLIVER
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:MARIE
Other - Last Name:CULBERTSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:PO BOX 390
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON
Mailing Address - State:WV
Mailing Address - Zip Code:25708-0390
Mailing Address - Country:US
Mailing Address - Phone:304-429-1088
Mailing Address - Fax:304-696-1623
Practice Address - Street 1:6276 COUNTY ROAD 107
Practice Address - Street 2:
Practice Address - City:PROCTORVILLE
Practice Address - State:OH
Practice Address - Zip Code:45669-8867
Practice Address - Country:US
Practice Address - Phone:888-221-1826
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-08-03
Last Update Date:2021-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV2555363AM0700X
OH50.003489363AM0700X
KYPA1634363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV1043598485Medicaid
KY7100179880Medicaid
KYP01094323OtherRR MEDICARE
OH0166746Medicaid
OH0166746Medicaid
OHH181991Medicare PIN