Provider Demographics
NPI:1568862910
Name:VICTORIUS, LISA (PA-C)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:VICTORIUS
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 1:235 S 33RD ST
Mailing Address - Street 2:WEIGHTMAN HALL
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19104-6322
Mailing Address - Country:US
Mailing Address - Phone:215-615-4400
Mailing Address - Fax:
Practice Address - Street 1:235 S 33RD ST
Practice Address - Street 2:WEIGHTMAN HALL
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19104-6322
Practice Address - Country:US
Practice Address - Phone:215-615-4400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-09-03
Last Update Date:2014-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA056967363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant