Provider Demographics
NPI:1366482531
Name:LISMAN, ELLEN SEGAL (PA-C)
Entity Type:Individual
Prefix:
First Name:ELLEN
Middle Name:SEGAL
Last Name:LISMAN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:ELLEN
Other - Middle Name:R
Other - Last Name:SEGAL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:2701 HOLME AVE
Mailing Address - Street 2:SUITE 203
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19152-2029
Mailing Address - Country:US
Mailing Address - Phone:215-331-0515
Mailing Address - Fax:215-331-8144
Practice Address - Street 1:2701 HOLME AVE
Practice Address - Street 2:SUITE 203
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19152-2029
Practice Address - Country:US
Practice Address - Phone:215-331-0515
Practice Address - Fax:215-331-8144
Is Sole Proprietor?:No
Enumeration Date:2006-06-07
Last Update Date:2010-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA003319L363AM0700X, 207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1045793OtherPHYSICIAN ASST LICENSE #
PAMA03319LMedicare UPIN