MEDICARE: MRS. LISA J HALL PA

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	363A00000X	Physician Assistant	0101029566	VA
2	363A00000X	Physician Assistant	0110002089	VA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	10019259P	OTHER	VA	OPTIMA

General Provider Information

NPI Number	:	1356349047
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. LISA J HALL PA

Provider Business Mailing Address
First Line	:	5900 LAKE WRIGHT DR
Second Line	:	SUITE 300
City	:	NORFOLK
State	:	VA
Zip	:	23502-1871
Country	:	US
Telephone Number	:	757-213-5700
Fax Number	:	757-213-5701

Provider Business Practice Location Address
First Line	:	1950 GLENN MITCHELL
Second Line	:	SUITE 102
City	:	VIRGINIA BEACH
State	:	VA
Zip	:	23456-0019
Country	:	US
Telephone Number	:	757-368-0437
Fax Number	:	757-368-0492

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

Provider Enumeration Date	:	07/07/2005
Last Update Date	:	06/16/2009

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