Provider Demographics
NPI:1366505406
Name:NEDLEY, LISA M (PA-C)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:M
Last Name:NEDLEY
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:
Other - Last Name:BONNAY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:9485 MENTOR AVENUE
Mailing Address - Street 2:SUITE 210
Mailing Address - City:MENTOR
Mailing Address - State:OH
Mailing Address - Zip Code:44060-1109
Mailing Address - Country:US
Mailing Address - Phone:440-255-5571
Mailing Address - Fax:440-205-5548
Practice Address - Street 1:9485 MENTOR AVENUE
Practice Address - Street 2:SUITE 210
Practice Address - City:MENTOR
Practice Address - State:OH
Practice Address - Zip Code:44060
Practice Address - Country:US
Practice Address - Phone:440-255-5571
Practice Address - Fax:440-205-5548
Is Sole Proprietor?:No
Enumeration Date:2006-12-19
Last Update Date:2021-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH50-00-1915363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHQ58461Medicare UPIN
OHBOPA26121Medicare ID - Type Unspecified