Provider Demographics
NPI:1376673046
Name:WHITESIDE, LISA A (PA-C)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:A
Last Name:WHITESIDE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:A
Other - Last Name:HERTEL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:PO BOX 781076
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48278-1076
Mailing Address - Country:US
Mailing Address - Phone:317-528-4800
Mailing Address - Fax:317-865-1479
Practice Address - Street 1:1205 HADLEY RD STE 130
Practice Address - Street 2:
Practice Address - City:MOORESVILLE
Practice Address - State:IN
Practice Address - Zip Code:46158-1934
Practice Address - Country:US
Practice Address - Phone:317-831-9340
Practice Address - Fax:317-834-5768
Is Sole Proprietor?:No
Enumeration Date:2007-03-06
Last Update Date:2023-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN10000872A363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical