Provider Demographics
NPI:1184111551
Name:GULISH, LISA (PA)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:GULISH
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 1:2410 NORTHSIDE DR
Mailing Address - Street 2:
Mailing Address - City:CLEARWATER
Mailing Address - State:FL
Mailing Address - Zip Code:33761-2236
Mailing Address - Country:US
Mailing Address - Phone:727-499-0356
Mailing Address - Fax:727-781-3312
Practice Address - Street 1:6 WOODLAND RD STE 304
Practice Address - Street 2:
Practice Address - City:SAINT HELENA
Practice Address - State:CA
Practice Address - Zip Code:94574-9562
Practice Address - Country:US
Practice Address - Phone:707-963-7200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-20
Last Update Date:2020-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9111231363A00000X
CA57797363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant