Provider Demographics
NPI:1518153949
Name:WAHL, LISA GAIL (ARNP)
Entity Type:Individual
Prefix:MS
First Name:LISA
Middle Name:GAIL
Last Name:WAHL
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3360
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97208-3360
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:420 GOLF CLUB RD SE
Practice Address - Street 2:SUITE 204
Practice Address - City:LACEY
Practice Address - State:WA
Practice Address - Zip Code:98503-1048
Practice Address - Country:US
Practice Address - Phone:360-493-7469
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-09-19
Last Update Date:2021-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP30007766363L00000X, 367A00000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA9654252Medicaid
WAAP30007766OtherWA LICENSE
WAG8888381OtherMEDICARE