Provider Demographics
NPI:1104252972
Name:LISK, SEAN ERVIN (PA-C)
Entity type:Individual
Prefix:
First Name:SEAN
Middle Name:ERVIN
Last Name:LISK
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:191 SPRING ST
Mailing Address - Street 2:
Mailing Address - City:SOUTH SALEM
Mailing Address - State:NY
Mailing Address - Zip Code:10590-1615
Mailing Address - Country:US
Mailing Address - Phone:207-661-2000
Mailing Address - Fax:
Practice Address - Street 1:20 YORK ST
Practice Address - Street 2:
Practice Address - City:NEW HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06510-3220
Practice Address - Country:US
Practice Address - Phone:203-688-2615
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-09-24
Last Update Date:2021-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPA1495363AM0700X
CT3811363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME1104252972Medicaid
ME1104252972Medicaid