Provider Demographics
NPI:1942372255
Name:BOWERSOX, LISA KAYE (PA-C)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:KAYE
Last Name:BOWERSOX
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 1:116 W MITCHELL ST
Mailing Address - Street 2:STE 1
Mailing Address - City:PETOSKEY
Mailing Address - State:MI
Mailing Address - Zip Code:49770-2357
Mailing Address - Country:US
Mailing Address - Phone:231-348-2828
Mailing Address - Fax:
Practice Address - Street 1:311 W MITCHELL ST
Practice Address - Street 2:
Practice Address - City:PETOSKEY
Practice Address - State:MI
Practice Address - Zip Code:49770-2327
Practice Address - Country:US
Practice Address - Phone:616-326-0114
Practice Address - Fax:231-487-6172
Is Sole Proprietor?:No
Enumeration Date:2006-11-14
Last Update Date:2023-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601004147363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant