=====================================================
General NPI Number Information
=====================================================
NPI Number | 1518101641
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LISA MATHEW CHERIAN PA
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/20/2009
-----------------------------------------------------
Last Update Date | 01/26/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1301 PENNSYLVANIA AVE
-----------------------------------------------------
City | FORT WORTH
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76104-2122
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 817-820-4906
-----------------------------------------------------
Fax | 817-820-4815
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2406 SILVER HOLLY LN
-----------------------------------------------------
City | RICHARDSON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75082-4208
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 214-529-0352
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363A00000X
-----------------------------------------------------
Taxonomy Name | Physician Assistant
-----------------------------------------------------
License Number | PA05975
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363AM0700X
-----------------------------------------------------
Taxonomy Name | Medical Physician Assistant
-----------------------------------------------------
License Number | PA05975
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------