Provider Demographics
NPI:1013340629
Name:WERNER, LISA ANNE (PA)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:ANNE
Last Name:WERNER
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:ANN
Other - Last Name:COLE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3860 W OGDEN AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60623-2460
Mailing Address - Country:US
Mailing Address - Phone:872-588-3000
Mailing Address - Fax:872-588-3001
Practice Address - Street 1:3860 W OGDEN AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60623-2460
Practice Address - Country:US
Practice Address - Phone:872-588-3000
Practice Address - Fax:872-588-3021
Is Sole Proprietor?:No
Enumeration Date:2013-08-19
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN2378363A00000X
IL085-005553363A00000X
IL085005553363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL385004177OtherCS LICENSE
IL085005553OtherSTATE LICENSE
IL1111165OtherSPECIALTY BOARDS
IL1111165OtherSPECIALTY BOARDS