Provider Demographics
NPI:1851325831
Name:WALLER, LISA M (PAC)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:M
Last Name:WALLER
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1100 LAKE HEARN DRIVE
Mailing Address - Street 2:STE 450
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30342
Mailing Address - Country:US
Mailing Address - Phone:404-252-7339
Mailing Address - Fax:404-257-0337
Practice Address - Street 1:1100 LAKE HEARN DRIVE
Practice Address - Street 2:STE #450
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30342
Practice Address - Country:US
Practice Address - Phone:404-252-7339
Practice Address - Fax:404-257-0337
Is Sole Proprietor?:No
Enumeration Date:2006-07-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH004516363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical