Provider Demographics
NPI:1467422089
Name:WOLF, LISA J (PAC)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:J
Last Name:WOLF
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 PATROON CREEK BLVD
Mailing Address - Street 2:SUITE 1
Mailing Address - City:ALBANY
Mailing Address - State:NY
Mailing Address - Zip Code:12206-5004
Mailing Address - Country:US
Mailing Address - Phone:518-489-0044
Mailing Address - Fax:
Practice Address - Street 1:400 PATROON CREEK BLVD
Practice Address - Street 2:SUITE 1
Practice Address - City:ALBANY
Practice Address - State:NY
Practice Address - Zip Code:12206-5004
Practice Address - Country:US
Practice Address - Phone:518-489-0044
Practice Address - Fax:518-489-3591
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-25
Last Update Date:2014-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY011597363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYP01083127OtherRAILROAD MEDICARE
P12524Medicare UPIN
J400005224Medicare PIN