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General NPI Number Information
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NPI Number | 1013505940
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Entity Type | Individual
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Provider Name | LISA FELLIS PA
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Gender | Female
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Dates
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Enumeration Date | 01/06/2021
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Last Update Date | 07/17/2024
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Provider Practice Location Address
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Address Line | 1200 TALISMAN DR
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City | NORTH AUGUSTA
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State | SC
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Zip | 29841-4032
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Country | US
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Telephone | 800-226-8874
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Fax |
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Provider Business Mailing Address
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Address Line | 3800 S OCEAN DR STE 209
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City | HOLLYWOOD
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State | FL
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Zip | 33019-2915
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Country | US
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Telephone | 800-226-8874
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Fax | 877-366-4776
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number | PA9113743
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License Number State | FL
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Taxonomy #3
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Taxonomy Code | 363AM0700X
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Taxonomy Name | Medical Physician Assistant
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License Number | PA9113743
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License Number State | FL
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Taxonomy #4
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number | 4964
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License Number State | SC
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