Provider Demographics
NPI:1558324293
Name:THOMAS, LISA M (PA-C)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:M
Last Name:THOMAS
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9200 W WISCONSIN AVE
Mailing Address - Street 2:CARDIOTHORACIC SURGERY
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53226-3522
Mailing Address - Country:US
Mailing Address - Phone:414-955-6900
Mailing Address - Fax:414-955-6204
Practice Address - Street 1:9200 W WISCONSIN AVE
Practice Address - Street 2:CARDIOTHORACIC SURGERY
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53226-3522
Practice Address - Country:US
Practice Address - Phone:414-955-6900
Practice Address - Fax:414-955-6204
Is Sole Proprietor?:No
Enumeration Date:2006-04-11
Last Update Date:2014-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1327-023363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1558324293Medicaid
WI42995000Medicaid
WI970029876OtherTRAVELERS MEDICARE
WI000501130Medicare ID - Type Unspecified
WI42995000Medicaid
WI1558324293Medicaid