Basic Information
| Provider Information | |||||||||
| NPI: | 1336561356 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LISAK | ||||||||
| FirstName: | WAYNE | ||||||||
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| NameSuffix: | II | ||||||||
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| Mailing Information | |||||||||
| Address1: | 750 STEPHENSON HWY | ||||||||
| Address2: | BEAUMONT PAYOR CONTRACT SERVICES | ||||||||
| City: | TROY | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480831103 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2485773511 | ||||||||
| FaxNumber: | 2485773526 | ||||||||
| Practice Location | |||||||||
| Address1: | 3601 W 13 MILE RD | ||||||||
| Address2: | ANESTHESIA | ||||||||
| City: | ROYAL OAK | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480736712 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2488985000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/10/2014 | ||||||||
| LastUpdateDate: | 01/10/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | 4704272201 | MI | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
No ID Information.