Provider Demographics
NPI:1982958054
Name:HAYES, LISA COLLEEN (PA-C)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:COLLEEN
Last Name:HAYES
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:COLLEEN
Other - Last Name:REIDY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:4310 WOODSIDE MANOR DR FL 33624
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33624-6719
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2100 VIA BELLA BLVD STE 201
Practice Address - Street 2:
Practice Address - City:LAND O LAKES
Practice Address - State:FL
Practice Address - Zip Code:34639-5429
Practice Address - Country:US
Practice Address - Phone:813-782-1234
Practice Address - Fax:813-355-5066
Is Sole Proprietor?:No
Enumeration Date:2012-10-29
Last Update Date:2023-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA 9106946363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLP01148873OtherR&R MEDICARE
FL007331200Medicaid
FL007331200Medicaid