Basic Information
| Provider Information | |||||||||
| NPI: | 1982958054 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HAYES | ||||||||
| FirstName: | LISA | ||||||||
| MiddleName: | COLLEEN | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | PA-C | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | REIDY | ||||||||
| OtherFirstName: | LISA | ||||||||
| OtherMiddleName: | COLLEEN | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | PA-C | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 38135 MARKET SQ | ||||||||
| Address2: | |||||||||
| City: | ZEPHYRHILLS | ||||||||
| State: | FL | ||||||||
| PostalCode: | 335427505 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3525670188 | ||||||||
| FaxNumber: | 8133555101 | ||||||||
| Practice Location | |||||||||
| Address1: | 2100 VIA BELLA BLVD STE 201 | ||||||||
| Address2: | |||||||||
| City: | LAND O LAKES | ||||||||
| State: | FL | ||||||||
| PostalCode: | 346395429 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8137821234 | ||||||||
| FaxNumber: | 8133555066 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/29/2012 | ||||||||
| LastUpdateDate: | 07/10/2019 | ||||||||
| 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 | PA 9106946 | FL | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | P01148873 | 01 | FL | R&R MEDICARE | OTHER | 007331200 | 05 | FL | MEDICAID |