MEDICARE: LISA GALLISHAW LYON 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	363A00000X	Physician Assistant	AMD 366	HI

General Provider Information

NPI Number	:	1821360819
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LISA GALLISHAW LYON PA-C

Provider Business Mailing Address
First Line	:	350 SUMNER ST
Second Line	:	SUMNER WELLNESS CLINIC
City	:	HONOLULU
State	:	HI
Zip	:	96817-5088
Country	:	US
Telephone Number	:	808-477-2925
Fax Number	:	808-537-2697

Provider Business Practice Location Address
First Line	:	15-2662 PAHOA VILLAGE RD
Second Line	:	SUITE 303 PMB 8741
City	:	PAHOA
State	:	HI
Zip	:	96778-7730
Country	:	US
Telephone Number	:	808-930-6001
Fax Number	:

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

Provider Enumeration Date	:	02/06/2012
Last Update Date	:	03/05/2015

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