Healthcare Provider Details

I. General information

NPI: 1053295063
Provider Name (Legal Business Name): MS. LISA ANDERSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/04/2025
Last Update Date: 09/12/2025
Certification Date: 09/12/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

UNIVERSITY OF TAMPA - DEPARTMENT OF PHYSICIAN ASSISTANT 401 W KENNEDY BLVD
TAMPA FL
33606
US

IV. Provider business mailing address

UNIVERSITY OF TAMPA - DEPARTMENT OF PHYSICIAN ASSISTANT 401 W KENNEDY BLVD
TAMPA FL
33606
US

V. Phone/Fax

Practice location:
  • Phone: 575-791-0262
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: