Provider Demographics
NPI:1619127677
Name:BURCHETT, LISA ANN (PA-C)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:ANN
Last Name:BURCHETT
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 1:3501 CATTLEMAN DR
Mailing Address - Street 2:
Mailing Address - City:MANCHACA
Mailing Address - State:TX
Mailing Address - Zip Code:78652-3112
Mailing Address - Country:US
Mailing Address - Phone:512-292-5904
Mailing Address - Fax:
Practice Address - Street 1:3501 CATTLEMAN DR
Practice Address - Street 2:
Practice Address - City:MANCHACA
Practice Address - State:TX
Practice Address - Zip Code:78652-3112
Practice Address - Country:US
Practice Address - Phone:512-292-5904
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-09-26
Last Update Date:2010-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA 00608363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXPA-00608OtherTEXAS MEDICAL LICENSE