Provider Demographics
NPI:1982688669
Name:NIELSEN, LISA K (PA-C)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:K
Last Name:NIELSEN
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 1:7309 N KNOXVILLE AVE
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61614-2085
Mailing Address - Country:US
Mailing Address - Phone:309-692-9898
Mailing Address - Fax:309-692-9055
Practice Address - Street 1:7309 N KNOXVILLE AVE
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61614-2085
Practice Address - Country:US
Practice Address - Phone:309-692-9898
Practice Address - Fax:309-692-9055
Is Sole Proprietor?:No
Enumeration Date:2005-12-06
Last Update Date:2020-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL85000333363AS0400X
363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILR78360Medicare UPIN
IL979010Medicare PIN
IL206673Medicare PIN
IL979013Medicare PIN