Provider Demographics
NPI:1821360819
Name:LYON, LISA GALLISHAW (PA-C)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:GALLISHAW
Last Name:LYON
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 1:350 SUMNER ST
Mailing Address - Street 2:SUMNER WELLNESS CLINIC
Mailing Address - City:HONOLULU
Mailing Address - State:HI
Mailing Address - Zip Code:96817-5088
Mailing Address - Country:US
Mailing Address - Phone:808-477-2925
Mailing Address - Fax:808-537-2697
Practice Address - Street 1:15-2662 PAHOA VILLAGE RD
Practice Address - Street 2:SUITE 303 PMB 8741
Practice Address - City:PAHOA
Practice Address - State:HI
Practice Address - Zip Code:96778-7730
Practice Address - Country:US
Practice Address - Phone:808-930-6001
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-02-06
Last Update Date:2015-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIAMD 366363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant