Provider Demographics
NPI:1922192350
Name:INNIS, LISA RAE (PA-C)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:RAE
Last Name:INNIS
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 1:75 SYLVANIA DR
Mailing Address - Street 2:
Mailing Address - City:BEAVERCREEK
Mailing Address - State:OH
Mailing Address - Zip Code:45440-3237
Mailing Address - Country:US
Mailing Address - Phone:937-320-5050
Mailing Address - Fax:937-320-2060
Practice Address - Street 1:75 SYLVANIA DR
Practice Address - Street 2:
Practice Address - City:BEAVERCREEK
Practice Address - State:OH
Practice Address - Zip Code:45440-3237
Practice Address - Country:US
Practice Address - Phone:937-320-5050
Practice Address - Fax:937-320-5060
Is Sole Proprietor?:No
Enumeration Date:2006-10-02
Last Update Date:2020-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA17447363A00000X
OH50.001303RX363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0385986Medicaid
CAS96003Medicare UPIN
CA0PA174470Medicaid