Provider Demographics
NPI:1245421031
Name:RADERSTORF, LISA D (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:LISA
Middle Name:D
Last Name:RADERSTORF
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:DAWN
Other - Last Name:NOLLENBERGER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:PO BOX 1239
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:MI
Mailing Address - Zip Code:48099-1239
Mailing Address - Country:US
Mailing Address - Phone:248-824-6600
Mailing Address - Fax:248-324-1477
Practice Address - Street 1:5838 W BRICK RD
Practice Address - Street 2:SUITE 106
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46628-8423
Practice Address - Country:US
Practice Address - Phone:574-247-1911
Practice Address - Fax:574-247-1912
Is Sole Proprietor?:No
Enumeration Date:2007-08-06
Last Update Date:2011-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN10000915A363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000527324OtherANTHEM BLUE CROSS
IN940670WWWWMedicare PIN