Healthcare Provider Details

I. General information

NPI: 1760834691
Provider Name (Legal Business Name): ALEXIS R LISKA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/02/2016
Last Update Date: 06/30/2026
Certification Date: 06/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15195 HEATHCOTE BLVD STE 240
HAYMARKET VA
20169-6245
US

IV. Provider business mailing address

PO BOX 748613
ATLANTA GA
30374-8613
US

V. Phone/Fax

Practice location:
  • Phone: 888-824-0200
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number0110011160
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number085007357
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: