Provider Demographics
NPI:1598837627
Name:HABERSBRUNNER, LISA M (PA)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:M
Last Name:HABERSBRUNNER
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:USACS
Mailing Address - Street 2:4535 DRESSLER RD NW
Mailing Address - City:CANTON
Mailing Address - State:OH
Mailing Address - Zip Code:44718-2545
Mailing Address - Country:US
Mailing Address - Phone:330-493-4443
Mailing Address - Fax:
Practice Address - Street 1:USACS
Practice Address - Street 2:4525 DRESSLER RD NW
Practice Address - City:CANTON
Practice Address - State:OH
Practice Address - Zip Code:44718-2545
Practice Address - Country:US
Practice Address - Phone:262-928-2475
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-14
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2057-023363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI42899800Medicaid
Q73078Medicare UPIN
WI0052Medicare PIN
WI0112Medicare PIN