Provider Demographics
NPI:1790177053
Name:FLATLEY, LISA A (PA-C)
Entity Type:Individual
Prefix:MS
First Name:LISA
Middle Name:A
Last Name:FLATLEY
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 1:1805 HIDDEN POND LN
Mailing Address - Street 2:
Mailing Address - City:TOMS RIVER
Mailing Address - State:NJ
Mailing Address - Zip Code:08755-1354
Mailing Address - Country:US
Mailing Address - Phone:732-349-6339
Mailing Address - Fax:
Practice Address - Street 1:1200 E RIDGEWOOD AVE STE 200
Practice Address - Street 2:
Practice Address - City:RIDGEWOOD
Practice Address - State:NJ
Practice Address - Zip Code:07450-3937
Practice Address - Country:US
Practice Address - Phone:908-522-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-02-24
Last Update Date:2016-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMP427363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant