Provider Demographics
NPI:1225267750
Name:WAHLESTEDT, LISA THORSON (MD)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:THORSON
Last Name:WAHLESTEDT
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:GAY
Other - Last Name:THORSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:212 AUSTRALIAN AVE
Mailing Address - Street 2:
Mailing Address - City:PALM BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33480-4626
Mailing Address - Country:US
Mailing Address - Phone:561-835-3875
Mailing Address - Fax:
Practice Address - Street 1:212 AUSTRALIAN AVE
Practice Address - Street 2:
Practice Address - City:PALM BEACH
Practice Address - State:FL
Practice Address - Zip Code:33480-4626
Practice Address - Country:US
Practice Address - Phone:561-835-3875
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-07-06
Last Update Date:2009-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME 1041702083P0901X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2083P0901XAllopathic & Osteopathic PhysiciansPreventive MedicinePublic Health & General Preventive Medicine