Provider Demographics
NPI:1013505940
Name:FELLIS, LISA (PA)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:FELLIS
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3800 S OCEAN DR STE 209
Mailing Address - Street 2:
Mailing Address - City:HOLLYWOOD
Mailing Address - State:FL
Mailing Address - Zip Code:33019-2915
Mailing Address - Country:US
Mailing Address - Phone:800-226-8874
Mailing Address - Fax:877-366-4776
Practice Address - Street 1:1200 TALISMAN DR
Practice Address - Street 2:
Practice Address - City:NORTH AUGUSTA
Practice Address - State:SC
Practice Address - Zip Code:29841-4032
Practice Address - Country:US
Practice Address - Phone:800-226-8874
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-06
Last Update Date:2024-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X
FLPA9113743363A00000X, 363AM0700X
SC4964363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical