Provider Demographics
NPI:1134305378
Name:WHEELER, LISA M (NP)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:M
Last Name:WHEELER
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3024 NIAGARA FALLS BLVD STE 116
Mailing Address - Street 2:
Mailing Address - City:NORTH TONAWANDA
Mailing Address - State:NY
Mailing Address - Zip Code:14120-1116
Mailing Address - Country:US
Mailing Address - Phone:716-217-4321
Mailing Address - Fax:716-219-2469
Practice Address - Street 1:3024 NIAGARA FALLS BLVD STE 116
Practice Address - Street 2:
Practice Address - City:NORTH TONAWANDA
Practice Address - State:NY
Practice Address - Zip Code:14120-1116
Practice Address - Country:US
Practice Address - Phone:716-217-4321
Practice Address - Fax:716-219-2469
Is Sole Proprietor?:No
Enumeration Date:2008-01-17
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF304201363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY000560977002OtherBC/BS
NY02740985Medicaid
NYMW1206871OtherDEA