Basic Information
| Provider Information | |||||||||
| NPI: | 1053427682 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SOBOLESKI | ||||||||
| FirstName: | LISA | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1220 DEWEY AVE | ||||||||
| Address2: | |||||||||
| City: | WAUWATOSA | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532132504 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4144546600 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1220 DEWEY AVE | ||||||||
| Address2: | |||||||||
| City: | WAUWATOSA | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532132504 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4144546600 | ||||||||
| FaxNumber: | 4144546450 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/23/2006 | ||||||||
| LastUpdateDate: | 03/19/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 763 | WI | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 42951200 | 05 | WI | MEDICAID |