MEDICARE: LISA A WHITESIDE PA-C

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	363AM0700X	Medical Physician Assistant	10000872A	IN

General Provider Information

NPI Number	:	1376673046
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LISA A WHITESIDE PA-C

Provider Business Mailing Address
First Line	:	PO BOX 781076
Second Line	:
City	:	DETROIT
State	:	MI
Zip	:	48278-1076
Country	:	US
Telephone Number	:	317-528-4800
Fax Number	:	317-865-1479

Provider Business Practice Location Address
First Line	:	1205 HADLEY RD STE 130
Second Line	:
City	:	MOORESVILLE
State	:	IN
Zip	:	46158-1934
Country	:	US
Telephone Number	:	317-831-9340
Fax Number	:	317-834-5768

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

Provider Enumeration Date	:	03/06/2007
Last Update Date	:	10/04/2023

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