Provider Demographics
NPI:1942520085
Name:VIVIAN, LISA M (PA)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:M
Last Name:VIVIAN
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:M
Other - Last Name:HIMES
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:100 HOSPITAL RD
Mailing Address - Street 2:
Mailing Address - City:BROOKVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:15825-1367
Mailing Address - Country:US
Mailing Address - Phone:814-849-0990
Mailing Address - Fax:814-849-0992
Practice Address - Street 1:22 INDUSTRIAL PARK RD
Practice Address - Street 2:
Practice Address - City:BROOKVILLE
Practice Address - State:PA
Practice Address - Zip Code:15825-7228
Practice Address - Country:US
Practice Address - Phone:814-849-0990
Practice Address - Fax:814-849-0992
Is Sole Proprietor?:No
Enumeration Date:2010-06-10
Last Update Date:2013-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA054395363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03253321Medicaid
PA1189114N8JMedicare PIN