Basic Information
| Provider Information | |||||||||
| NPI: | 1780780726 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SHEVLIN | ||||||||
| FirstName: | LISA | ||||||||
| MiddleName: | E | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 360 LINDEN OAKS | ||||||||
| Address2: | SUITE #300 | ||||||||
| City: | ROCHESTER | ||||||||
| State: | NY | ||||||||
| PostalCode: | 146252814 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5853838830 | ||||||||
| FaxNumber: | 5853838918 | ||||||||
| Practice Location | |||||||||
| Address1: | 360 LINDEN OAKS | ||||||||
| Address2: | SUITE #300 | ||||||||
| City: | ROCHESTER | ||||||||
| State: | NY | ||||||||
| PostalCode: | 146252814 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5853838830 | ||||||||
| FaxNumber: | 5853838918 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/16/2006 | ||||||||
| LastUpdateDate: | 03/21/2014 | ||||||||
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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 | 363AS0400X | 010080 | NY | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical |
ID Information
| ID | Type | State | Issuer | Description | 03124247 | 05 | NY | MEDICAID |