Healthcare Provider Details

I. General information

NPI: 1336381136
Provider Name (Legal Business Name): LISA ANN SHEA PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/25/2009
Last Update Date: 04/23/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1550 RICHMOND AVE SUITE 207
STATEN ISLAND NY
10314-1578
US

IV. Provider business mailing address

1550 RICHMOND AVE
STATEN ISLAND NY
10314-1510
US

V. Phone/Fax

Practice location:
  • Phone: 718-698-1616
  • Fax: 718-698-9573
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number010434
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: