Provider Demographics
NPI:1629175401
Name:SALYARDS, LISA K (PA-C)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:K
Last Name:SALYARDS
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 1:1900 ELECTRIC RD
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:VA
Mailing Address - Zip Code:24153-7474
Mailing Address - Country:US
Mailing Address - Phone:540-776-4000
Mailing Address - Fax:540-776-2083
Practice Address - Street 1:1900 ELECTRIC RD
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:VA
Practice Address - Zip Code:24153-7474
Practice Address - Country:US
Practice Address - Phone:540-776-4000
Practice Address - Fax:540-776-2083
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2009-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110002044363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAP00453920OtherRAILROAD MEDICARE
VA1629175401Medicaid
VA1629175401Medicaid
VA020940S90Medicare PIN
Q44649Medicare UPIN
VA016149L84Medicare PIN