Healthcare Provider Details

I. General information

NPI: 1053517011
Provider Name (Legal Business Name): LISA ANN WAUGH LMT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/26/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1109 JEFFERSON RD
S CHARLESTON WV
25309-9780
US

IV. Provider business mailing address

2939 SHADYSIDE RD
ST ALBANS WV
25177
US

V. Phone/Fax

Practice location:
  • Phone: 304-610-7888
  • Fax:
Mailing address:
  • Phone: 304-610-7888
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code204C00000X
TaxonomySports Medicine (Neuromusculoskeletal Medicine) Physician
License Number0388
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: