Provider Demographics
NPI:1639287352
Name:MITCHELL, LISA M (PA)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:M
Last Name:MITCHELL
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 1:38 VANDERBILT AVE
Mailing Address - Street 2:SUITE F
Mailing Address - City:NORWOOD
Mailing Address - State:MA
Mailing Address - Zip Code:02062
Mailing Address - Country:US
Mailing Address - Phone:718-762-2800
Mailing Address - Fax:781-762-2888
Practice Address - Street 1:38 VANDERBILT AVE
Practice Address - Street 2:
Practice Address - City:NORWOOD
Practice Address - State:MA
Practice Address - Zip Code:02062
Practice Address - Country:US
Practice Address - Phone:718-762-2800
Practice Address - Fax:781-762-2800
Is Sole Proprietor?:No
Enumeration Date:2006-08-25
Last Update Date:2023-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA000456363A00000X
MAPA456363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
41053OtherRI BLUE CHIP
41053OtherRI BLUE CHIP
MAS45157Medicare UPIN