Healthcare Provider Details

I. General information

NPI: 1487082392
Provider Name (Legal Business Name): LISA HUTCHESON PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/31/2013
Last Update Date: 10/31/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

745 GLYNN ST S
FAYETTEVILLE GA
30214-2049
US

IV. Provider business mailing address

4412 AUTUMN GLO CT
DOUGLASVILLE GA
30135-5097
US

V. Phone/Fax

Practice location:
  • Phone: 770-719-5490
  • Fax: 770-719-3113
Mailing address:
  • Phone: 404-610-9998
  • Fax: 770-719-3113

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number2572
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: