Provider Demographics
NPI:1689667222
Name:MAHON, LISA D (PA)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:D
Last Name:MAHON
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:
Other - Last Name:DOYLE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:5719 WIDEWATERS PKWY
Mailing Address - Street 2:
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13214-1880
Mailing Address - Country:US
Mailing Address - Phone:315-251-3100
Mailing Address - Fax:315-449-9923
Practice Address - Street 1:5719 WIDEWATERS PKWY
Practice Address - Street 2:
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13214-1880
Practice Address - Country:US
Practice Address - Phone:315-251-3100
Practice Address - Fax:315-449-9923
Is Sole Proprietor?:No
Enumeration Date:2005-08-30
Last Update Date:2011-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY008455363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
P42124Medicare UPIN