Provider Demographics
NPI:1821094392
Name:LEY, LISA T (PA-C)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:T
Last Name:LEY
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 1:3400 W 66TH ST
Mailing Address - Street 2:STE 385
Mailing Address - City:EDINA
Mailing Address - State:MN
Mailing Address - Zip Code:55435-2197
Mailing Address - Country:US
Mailing Address - Phone:952-920-2761
Mailing Address - Fax:
Practice Address - Street 1:3400 W 66TH ST
Practice Address - Street 2:STE 385
Practice Address - City:EDINA
Practice Address - State:MN
Practice Address - Zip Code:55435-2197
Practice Address - Country:US
Practice Address - Phone:952-920-2761
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-06-21
Last Update Date:2010-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN9570363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN135142700Medicaid
MN010D3KROtherBCBS MINNESOTA
MN010D3KROtherBCBS MINNESOTA