Healthcare Provider Details

I. General information

NPI: 1295287043
Provider Name (Legal Business Name): LISA M BUSCHLEN PAC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/27/2016
Last Update Date: 06/13/2024
Certification Date: 06/13/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1805 TIFT AVE N STE D
TIFTON GA
31794-3579
US

IV. Provider business mailing address

1805 TIFT AVE N STE D
TIFTON GA
31794-3579
US

V. Phone/Fax

Practice location:
  • Phone: 229-382-5554
  • Fax: 229-382-0530
Mailing address:
  • Phone: 229-382-5554
  • Fax: 229-382-0530

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA1673
License Number StateME
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number12209
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: