Provider Demographics
NPI:1245298850
Name:WARREN, LISA K (PA)
Entity type:Individual
Prefix:MS
First Name:LISA
Middle Name:K
Last Name:WARREN
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 1:1827 FARMSTEAD ST
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67208-1745
Mailing Address - Country:US
Mailing Address - Phone:316-650-9837
Mailing Address - Fax:
Practice Address - Street 1:2901 W 101ST ST N
Practice Address - Street 2:
Practice Address - City:VALLEY CENTER
Practice Address - State:KS
Practice Address - Zip Code:67147
Practice Address - Country:US
Practice Address - Phone:316-650-9837
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-03
Last Update Date:2020-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS1500813363A00000X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS100422140FMedicaid
KS100422140IMedicaid
KSP59545Medicare UPIN