Provider Demographics
NPI:1689765018
Name:HENSON, LISA MARIE (PA-C)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:MARIE
Last Name:HENSON
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 1:787 COUNTY HIGHWAY 54
Mailing Address - Street 2:
Mailing Address - City:CHERRY VALLEY
Mailing Address - State:NY
Mailing Address - Zip Code:13320-2003
Mailing Address - Country:US
Mailing Address - Phone:518-588-0866
Mailing Address - Fax:
Practice Address - Street 1:1 ATWELL RD
Practice Address - Street 2:
Practice Address - City:COOPERSTOWN
Practice Address - State:NY
Practice Address - Zip Code:13326-1301
Practice Address - Country:US
Practice Address - Phone:607-547-6982
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-28
Last Update Date:2009-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0114871363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant