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General NPI Number Information
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NPI Number | 1053517011
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Entity Type | Individual
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Provider Name | LISA ANN WAUGH LMT
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Gender | Female
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Dates
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Enumeration Date | 06/26/2007
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Last Update Date | 07/08/2007
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Provider Practice Location Address
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Address Line | 1109 JEFFERSON RD
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City | S CHARLESTON
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State | WV
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Zip | 25309-9780
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Country | US
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Telephone | 304-610-7888
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Fax |
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Provider Business Mailing Address
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Address Line | 2939 SHADYSIDE RD
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City | ST ALBANS
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State | WV
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Zip | 25177
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Country | US
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Telephone | 304-610-7888
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Fax |
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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 | 204C00000X
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Taxonomy Name | Sports Medicine (Neuromusculoskeletal Medicine) Physician
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License Number | 0388
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License Number State | WV
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