Provider Demographics
NPI:1245421031
Name:RADERSTORF, LISA D (PA-C)
Entity type:Individual
Prefix:MS
First Name:LISA
Middle Name:D
Last Name:RADERSTORF
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MISS
Other - First Name:LISA
Other - Middle Name:DAWN
Other - Last Name:NOLLENBERGER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:41800 W 11 MILE RD STE 109
Mailing Address - Street 2:
Mailing Address - City:NOVI
Mailing Address - State:MI
Mailing Address - Zip Code:48375-1818
Mailing Address - Country:US
Mailing Address - Phone:248-660-1220
Mailing Address - Fax:
Practice Address - Street 1:41800 W 11 MILE RD STE 109
Practice Address - Street 2:
Practice Address - City:NOVI
Practice Address - State:MI
Practice Address - Zip Code:48375-1818
Practice Address - Country:US
Practice Address - Phone:248-660-1220
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-08-06
Last Update Date:2024-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601006281363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000527324OtherANTHEM BLUE CROSS
IN940670WWWWMedicare PIN