Provider Demographics
NPI:1073669172
Name:PANISH, LISA PAULETTE
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:PAULETTE
Last Name:PANISH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:PAULETTE
Other - Last Name:WILSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:9009 CORPORATE LAKE DR
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33634-2367
Mailing Address - Country:US
Mailing Address - Phone:727-433-0157
Mailing Address - Fax:
Practice Address - Street 1:9009 CORPORATE LAKE DR
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33634-2367
Practice Address - Country:US
Practice Address - Phone:727-433-0157
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-25
Last Update Date:2019-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN2975062363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLU37292Medicare ID - Type Unspecified
FLS74989Medicare UPIN