Provider Demographics
NPI:1134373491
Name:TSHUMA, LISA (PA)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:TSHUMA
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 1:321 W SOUTHLAKE BLVD
Mailing Address - Street 2:SUITE #180
Mailing Address - City:SOUTHLAKE
Mailing Address - State:TX
Mailing Address - Zip Code:76092-6188
Mailing Address - Country:US
Mailing Address - Phone:817-416-2905
Mailing Address - Fax:817-416-7284
Practice Address - Street 1:321 W SOUTHLAKE BLVD
Practice Address - Street 2:SUITE #180
Practice Address - City:SOUTHLAKE
Practice Address - State:TX
Practice Address - Zip Code:76092-6188
Practice Address - Country:US
Practice Address - Phone:817-416-2905
Practice Address - Fax:817-416-7284
Is Sole Proprietor?:No
Enumeration Date:2008-11-12
Last Update Date:2013-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-01600363A00000X
TXPA07202363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX886N95OtherBCBS
TX308009501Medicaid
TXTXB165395Medicare PIN