Healthcare Provider Details

I. General information

NPI: 1053065680
Provider Name (Legal Business Name): LISA JOAN NELSON PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/11/2022
Last Update Date: 05/13/2026
Certification Date: 05/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

789 PRE EMPTION RD
GENEVA NY
14456-2069
US

IV. Provider business mailing address

601B W WASHINGTON ST
GENEVA NY
14456-2119
US

V. Phone/Fax

Practice location:
  • Phone: 315-781-2000
  • Fax:
Mailing address:
  • Phone: 315-787-8151
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number029049
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: