Healthcare Provider Details

I. General information

NPI: 1295810448
Provider Name (Legal Business Name): LISA MARIE BASYE PAC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: LISA MARIE LUDWIG PAC

II. Dates (important events)

Enumeration Date: 10/26/2006
Last Update Date: 02/25/2025
Certification Date: 02/25/2025
Deactivation Date: 02/05/2009
Reactivation Date: 03/09/2009

III. Provider practice location address

17978 STATE RT. 55
BAKER WV
26801-0097
US

IV. Provider business mailing address

1900 SPERRY RUN RD
RIO WV
26755
US

V. Phone/Fax

Practice location:
  • Phone: 304-897-5915
  • Fax:
Mailing address:
  • Phone: 304-897-5933
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number345
License Number StateWV
# 2
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: