Basic Information
Provider Information | |||||||||
NPI: | 1205085321 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | WALL | ||||||||
FirstName: | LISA | ||||||||
MiddleName: | LAURA | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | P.A. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | GUIDA | ||||||||
OtherFirstName: | LISA | ||||||||
OtherMiddleName: | LAURA | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | P.A. | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 151 SOUTHHALL LN STE 300 | ||||||||
Address2: |   | ||||||||
City: | MAITLAND | ||||||||
State: | FL | ||||||||
PostalCode: | 327517172 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4078752080 | ||||||||
FaxNumber: | 4076503455 | ||||||||
Practice Location | |||||||||
Address1: | 484 US HIGHWAY 1 STE C | ||||||||
Address2: |   | ||||||||
City: | SEBASTIAN | ||||||||
State: | FL | ||||||||
PostalCode: | 329588454 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7726466100 | ||||||||
FaxNumber: | 7726466110 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/12/2008 | ||||||||
LastUpdateDate: | 07/21/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 25MP00107400 | NJ | N |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |   | 363A00000X |   | FL | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |   |
ID Information
ID | Type | State | Issuer | Description | IM816Z | 01 | FL | MEDICARE PTAN | OTHER | 017124100 | 05 | FL |   | MEDICAID |