Healthcare Provider Details

I. General information

NPI: 1659692176
Provider Name (Legal Business Name): LISA A CHILDRESS PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/18/2010
Last Update Date: 02/22/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

820 RAVENHILL DR SUITE 107
ATCHISON KS
66002-9268
US

IV. Provider business mailing address

820 RAVENHILL DR SUITE 107
ATCHISON KS
66002-9268
US

V. Phone/Fax

Practice location:
  • Phone: 913-367-5496
  • Fax: 913-674-2039
Mailing address:
  • Phone: 913-367-5496
  • Fax: 913-674-2039

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number10735
License Number StateMN
# 2
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number15-01594
License Number StateKS

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: