Provider Demographics
NPI:1659692176
Name:CHILDRESS, LISA A (PA-C)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:A
Last Name:CHILDRESS
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:820 RAVENHILL DR
Mailing Address - Street 2:SUITE 107
Mailing Address - City:ATCHISON
Mailing Address - State:KS
Mailing Address - Zip Code:66002-9268
Mailing Address - Country:US
Mailing Address - Phone:913-367-5496
Mailing Address - Fax:913-674-2039
Practice Address - Street 1:820 RAVENHILL DR
Practice Address - Street 2:SUITE 107
Practice Address - City:ATCHISON
Practice Address - State:KS
Practice Address - Zip Code:66002-9268
Practice Address - Country:US
Practice Address - Phone:913-367-5496
Practice Address - Fax:913-674-2039
Is Sole Proprietor?:No
Enumeration Date:2010-06-18
Last Update Date:2013-02-22
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MN10735363AS0400X
KS15-01594363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical