Healthcare Provider Details

I. General information

NPI: 1588698013
Provider Name (Legal Business Name): LISA MARIE WETHERHOLD PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/10/2006
Last Update Date: 03/26/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

333 COTTMAN AVE
PHILADELPHIA PA
19111-2434
US

IV. Provider business mailing address

2450 W HUNTING PARK AVE
PHILADELPHIA PA
19129-1302
US

V. Phone/Fax

Practice location:
  • Phone: 215-728-6900
  • Fax: 215-728-5507
Mailing address:
  • Phone: 215-728-6900
  • Fax: 215-728-5507

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberMA052648
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: