Provider Demographics
NPI:1013916568
Name:EVERITT, LISA A (PA)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:A
Last Name:EVERITT
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 1:5900 LAKE WRIGHT DR
Mailing Address - Street 2:SUITE 300
Mailing Address - City:NORFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23502-1871
Mailing Address - Country:US
Mailing Address - Phone:757-213-5700
Mailing Address - Fax:757-213-5701
Practice Address - Street 1:5900 LAKE WRIGHT DR
Practice Address - Street 2:
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23502-1871
Practice Address - Country:US
Practice Address - Phone:757-466-8683
Practice Address - Fax:757-466-0250
Is Sole Proprietor?:No
Enumeration Date:2005-07-18
Last Update Date:2008-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110001877363AM0700X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA10019822POtherOPTIMA
VA1013916568Medicaid
VA1013916568Medicaid
VA10019822POtherOPTIMA
VAMC10591Medicare PIN