Provider Demographics
NPI:1780777169
Name:JARVIS, LISA A (PA)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:A
Last Name:JARVIS
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:A
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:777 AVE H
Mailing Address - Street 2:
Mailing Address - City:POWELL
Mailing Address - State:WY
Mailing Address - Zip Code:82435
Mailing Address - Country:US
Mailing Address - Phone:307-754-7257
Mailing Address - Fax:307-754-7217
Practice Address - Street 1:777 AVENUE H
Practice Address - Street 2:
Practice Address - City:POWELL
Practice Address - State:WY
Practice Address - Zip Code:82435
Practice Address - Country:US
Practice Address - Phone:307-754-7257
Practice Address - Fax:307-754-7217
Is Sole Proprietor?:No
Enumeration Date:2006-09-30
Last Update Date:2015-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI877363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI42957600Medicaid
S66953Medicare UPIN
WI008139295Medicare ID - Type Unspecified