Provider Demographics
NPI:1275087595
Name:BECKWITH, LISA M
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:M
Last Name:BECKWITH
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 1:818 ELLICOTT ST
Mailing Address - Street 2:
Mailing Address - City:BUFFALO
Mailing Address - State:NY
Mailing Address - Zip Code:14203-1021
Mailing Address - Country:US
Mailing Address - Phone:716-323-1294
Mailing Address - Fax:
Practice Address - Street 1:818 ELLICOTT ST
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14203-1021
Practice Address - Country:US
Practice Address - Phone:716-323-1294
Practice Address - Fax:716-323-1312
Is Sole Proprietor?:No
Enumeration Date:2016-08-04
Last Update Date:2019-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY340899363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily