Provider Demographics
NPI:1205975232
Name:FORESTAL, LISA MARIE (PA)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:MARIE
Last Name:FORESTAL
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:MARIE
Other - Last Name:WELLER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3435 MAIN ST
Mailing Address - Street 2:HAYES A
Mailing Address - City:BUFFALO
Mailing Address - State:NY
Mailing Address - Zip Code:14214-3001
Mailing Address - Country:US
Mailing Address - Phone:716-829-3670
Mailing Address - Fax:
Practice Address - Street 1:100 HIGH ST
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14203-1126
Practice Address - Country:US
Practice Address - Phone:716-859-1254
Practice Address - Fax:716-859-4586
Is Sole Proprietor?:No
Enumeration Date:2007-02-06
Last Update Date:2009-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY011316363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY011316OtherPA LICENSE