Provider Demographics
NPI:1184736795
Name:LIS, THOMAS S (PA-C, MPH)
Entity type:Individual
Prefix:
First Name:THOMAS
Middle Name:S
Last Name:LIS
Suffix:
Gender:M
Credentials:PA-C, MPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:411 OAK STREET
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45219
Mailing Address - Country:US
Mailing Address - Phone:513-984-1800
Mailing Address - Fax:513-984-4909
Practice Address - Street 1:PSC 7 BOX 801
Practice Address - Street 2:APO
Practice Address - City:APO
Practice Address - State:AE
Practice Address - Zip Code:09104
Practice Address - Country:US
Practice Address - Phone:01149245-199-3382
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2012-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA690363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAAP0839Medicare ID - Type Unspecified
S56265Medicare UPIN