Provider Demographics
NPI:1700049228
Name:REARDON, LISA MARIE (PA-C)
Entity Type:Individual
Prefix:MS
First Name:LISA
Middle Name:MARIE
Last Name:REARDON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:560 GAGE BLVD
Mailing Address - Street 2:SUITE 203
Mailing Address - City:RICHLAND
Mailing Address - State:WA
Mailing Address - Zip Code:99352
Mailing Address - Country:US
Mailing Address - Phone:509-942-3627
Mailing Address - Fax:509-942-2268
Practice Address - Street 1:4008 W 27TH AVE, SUITE 103
Practice Address - Street 2:
Practice Address - City:KENNEWICK
Practice Address - State:WA
Practice Address - Zip Code:99337
Practice Address - Country:US
Practice Address - Phone:509-942-2355
Practice Address - Fax:509-222-1289
Is Sole Proprietor?:No
Enumeration Date:2008-07-03
Last Update Date:2016-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORPA00739363AM0700X
WAPA60423341363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1700049228Medicaid