Provider Demographics
NPI:1598031015
Name:SERVICE, LISA MARIE (PA-C)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:MARIE
Last Name:SERVICE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:MARIE
Other - Last Name:CLARKE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:900 S PINE ISLAND RD
Mailing Address - Street 2:
Mailing Address - City:PLANTATION
Mailing Address - State:FL
Mailing Address - Zip Code:33324-3920
Mailing Address - Country:US
Mailing Address - Phone:305-821-8611
Mailing Address - Fax:305-827-1753
Practice Address - Street 1:15507 NW 67TH AVE
Practice Address - Street 2:
Practice Address - City:MIAMI LAKES
Practice Address - State:FL
Practice Address - Zip Code:33014-2108
Practice Address - Country:US
Practice Address - Phone:305-821-8611
Practice Address - Fax:305-827-1753
Is Sole Proprietor?:No
Enumeration Date:2012-03-29
Last Update Date:2019-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9105791172V00000X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No172V00000XOther Service ProvidersCommunity Health Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL007661300Medicaid