Provider Demographics
NPI:1740303205
Name:WARACK, LISA MARIE (PA-C)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:MARIE
Last Name:WARACK
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4790 W M 76
Mailing Address - Street 2:
Mailing Address - City:WEST BRANCH
Mailing Address - State:MI
Mailing Address - Zip Code:48661-8921
Mailing Address - Country:US
Mailing Address - Phone:989-345-2791
Mailing Address - Fax:
Practice Address - Street 1:2463 S M 30
Practice Address - Street 2:
Practice Address - City:WEST BRANCH
Practice Address - State:MI
Practice Address - Zip Code:48661-9312
Practice Address - Country:US
Practice Address - Phone:989-343-3261
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-09
Last Update Date:2013-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601004189363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
Q37966Medicare UPIN
MIN852400005Medicare PIN