Provider Demographics
NPI:1124027339
Name:SIMONIAN, LISA
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:SIMONIAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2500 W 12TH ST STE C
Mailing Address - Street 2:SUITE C
Mailing Address - City:ERIE
Mailing Address - State:PA
Mailing Address - Zip Code:16505-4500
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2500 W 12TH ST STE C
Practice Address - Street 2:SUITE C
Practice Address - City:ERIE
Practice Address - State:PA
Practice Address - Zip Code:16505-4500
Practice Address - Country:US
Practice Address - Phone:814-877-8730
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-07-19
Last Update Date:2021-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PATP007016B363L00000X, 207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02218573OtherNY MEDICAL ASSISTANCE
PA500026874OtherRR MEDICARE
WV1068760OtherWEST VIRGINIA WORK COMP
PA1731266OtherBLUE SHIELD
WV1068760OtherWEST VIRGINIA WORK COMP
PA500026874OtherRR MEDICARE