Provider Demographics
NPI:1518099340
Name:SOWELS, LISA DENISE (PA-C)
Entity Type:Individual
Prefix:MS
First Name:LISA
Middle Name:DENISE
Last Name:SOWELS
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:DENISE
Other - Last Name:GRIFFIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:36123 SCHOOLCRAFT RD
Mailing Address - Street 2:
Mailing Address - City:LIVONIA
Mailing Address - State:MI
Mailing Address - Zip Code:48150-1216
Mailing Address - Country:US
Mailing Address - Phone:734-464-0887
Mailing Address - Fax:734-402-0254
Practice Address - Street 1:306 TOWN CENTER DR
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:MI
Practice Address - Zip Code:48084-1742
Practice Address - Country:US
Practice Address - Phone:248-720-0277
Practice Address - Fax:248-720-0276
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-09
Last Update Date:2015-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601001985363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0P04280Medicare ID - Type UnspecifiedID NUMBER