Basic Information
Provider Information | |||||||||
NPI: | 1356349047 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | HALL | ||||||||
FirstName: | LISA | ||||||||
MiddleName: | J | ||||||||
NamePrefix: | MRS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | PA | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | HOWE | ||||||||
OtherFirstName: | LISA | ||||||||
OtherMiddleName: | J | ||||||||
OtherNamePrefix: | MISS | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | PA | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 5900 LAKE WRIGHT DR | ||||||||
Address2: | SUITE 300 | ||||||||
City: | NORFOLK | ||||||||
State: | VA | ||||||||
PostalCode: | 235021871 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7572135700 | ||||||||
FaxNumber: | 7572135701 | ||||||||
Practice Location | |||||||||
Address1: | 1950 GLENN MITCHELL | ||||||||
Address2: | SUITE 102 | ||||||||
City: | VIRGINIA BEACH | ||||||||
State: | VA | ||||||||
PostalCode: | 234560019 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7573680437 | ||||||||
FaxNumber: | 7573680492 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/07/2005 | ||||||||
LastUpdateDate: | 06/16/2009 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 0101029566 | VA | N |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |   | 363A00000X | 0110002089 | VA | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |   |
ID Information
ID | Type | State | Issuer | Description | 10019259P | 01 | VA | OPTIMA | OTHER |