MEDICARE: LISA SIMONIAN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363L00000X	Nurse Practitioner	TP007016B	PA

General Provider Information

NPI Number	:	1124027339
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LISA SIMONIAN

Provider Business Mailing Address
First Line	:	2500 W 12TH ST STE C
Second Line	:	SUITE C
City	:	ERIE
State	:	PA
Zip	:	16505-4500
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2500 W 12TH ST STE C
Second Line	:	SUITE C
City	:	ERIE
State	:	PA
Zip	:	16505-4500
Country	:	US
Telephone Number	:	814-877-8730
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/19/2005
Last Update Date	:	03/25/2021

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Directions to “ LISA SIMONIAN ” Practice Location

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