Provider Demographics
NPI:1205085321
Name:WALL, LISA LAURA (PA)
Entity type:Individual
Prefix:MRS
First Name:LISA
Middle Name:LAURA
Last Name:WALL
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:LAURA
Other - Last Name:GUIDA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:151 SOUTHHALL LN STE 300
Mailing Address - Street 2:
Mailing Address - City:MAITLAND
Mailing Address - State:FL
Mailing Address - Zip Code:32751-7172
Mailing Address - Country:US
Mailing Address - Phone:407-875-2080
Mailing Address - Fax:407-650-3455
Practice Address - Street 1:3755 7TH TER STE 101
Practice Address - Street 2:
Practice Address - City:VERO BEACH
Practice Address - State:FL
Practice Address - Zip Code:32960-6531
Practice Address - Country:US
Practice Address - Phone:772-569-5056
Practice Address - Fax:772-562-5098
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-12
Last Update Date:2024-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MP00107400363A00000X
FL363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLIM816ZOtherMEDICARE PTAN
FL017124100Medicaid
NJ157626C2HMedicare PIN