Provider Demographics
NPI:1780760835
Name:HOSTETLER, LISA LYNETTE (MD, PHD)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:LYNETTE
Last Name:HOSTETLER
Suffix:
Gender:F
Credentials:MD, PHD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:500 EVERGREEN DR
Mailing Address - Street 2:SUITE 20
Mailing Address - City:GLEN MILLS
Mailing Address - State:PA
Mailing Address - Zip Code:19342-1032
Mailing Address - Country:US
Mailing Address - Phone:484-785-3376
Mailing Address - Fax:610-544-8655
Practice Address - Street 1:500 EVERGREEN DRIVE
Practice Address - Street 2:SUITE 20
Practice Address - City:GLEN MILLS
Practice Address - State:PA
Practice Address - Zip Code:19342
Practice Address - Country:US
Practice Address - Phone:484-785-3376
Practice Address - Fax:610-544-8655
Is Sole Proprietor?:No
Enumeration Date:2006-10-31
Last Update Date:2014-09-10
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
PAMD047581L207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA469367OtherAETNA
PA0233208000OtherIBC
PA421165OtherBLUE SHIELD
PA421165FB7Medicare PIN
PA0233208000OtherIBC
PA070010986Medicare PIN