Basic Information
| Provider Information | |||||||||
| NPI: | 1740445519 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WALTER | ||||||||
| FirstName: | LISA | ||||||||
| MiddleName: | A | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | N.P. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | RAYMOND | ||||||||
| OtherFirstName: | LISA | ||||||||
| OtherMiddleName: | A | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | N.P. | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 117 FOOTE AVE | ||||||||
| Address2: | |||||||||
| City: | JAMESTOWN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 147016947 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7163389500 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 117 FOOTE AVENUE | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | JAMESTOWN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 14701 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7163389200 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/22/2008 | ||||||||
| LastUpdateDate: | 07/25/2016 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
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| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | F335710-1 | NY | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 9515406 | 01 | NY | IHA | OTHER | 03064697 | 05 | NY | MEDICAID | 0569838 | 01 | NY | GHI | OTHER | 000531082001 | 01 | NY | BCBS | OTHER |