Provider Demographics
NPI: | 1790154508 |
---|---|
Name: | SOWAR, LISA MARIE (PNP) |
Entity Type: | Individual |
Prefix: | MRS |
First Name: | LISA |
Middle Name: | MARIE |
Last Name: | SOWAR |
Suffix: | |
Gender: | F |
Credentials: | PNP |
Other - Prefix: | |
Other - First Name: | |
Other - Middle Name: | |
Other - Last Name: | |
Other - Suffix: | |
Other - Last Name Type: | |
Other - Credentials: | |
Mailing Address - Street 1: | PO BOX 933432 |
Mailing Address - Street 2: | |
Mailing Address - City: | CLEVELAND |
Mailing Address - State: | OH |
Mailing Address - Zip Code: | 44193-0039 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 937-641-5072 |
Mailing Address - Fax: | |
Practice Address - Street 1: | 662 N MAIN ST |
Practice Address - Street 2: | |
Practice Address - City: | SPRINGBORO |
Practice Address - State: | OH |
Practice Address - Zip Code: | 45066-9553 |
Practice Address - Country: | US |
Practice Address - Phone: | 937-641-5066 |
Practice Address - Fax: | 937-550-9797 |
Is Sole Proprietor?: | No |
Enumeration Date: | 2015-09-22 |
Last Update Date: | 2023-10-12 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
OH | APRN.CNP.18047 | 363LA2100X, 363LA2100X |
OH | COA.18047-NP | 363LP0200X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 363LP0200X | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Pediatrics |
Yes | 363LA2100X | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Acute Care |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
OH | 0329698 | Medicaid |