Healthcare Provider Details

I. General information

NPI: 1376673046
Provider Name (Legal Business Name): LISA A WHITESIDE PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: LISA A HERTEL PA-C

II. Dates (important events)

Enumeration Date: 03/06/2007
Last Update Date: 10/04/2023
Certification Date: 10/04/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1205 HADLEY RD STE 130
MOORESVILLE IN
46158-1934
US

IV. Provider business mailing address

PO BOX 781076
DETROIT MI
48278-1076
US

V. Phone/Fax

Practice location:
  • Phone: 317-831-9340
  • Fax: 317-834-5768
Mailing address:
  • Phone: 317-528-4800
  • Fax: 317-865-1479

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number10000872A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: