Provider Demographics
NPI:1104533298
Name:WYMER, LISA
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:WYMER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1529 UNION ST APT A
Mailing Address - Street 2:
Mailing Address - City:ALAMEDA
Mailing Address - State:CA
Mailing Address - Zip Code:94501-2681
Mailing Address - Country:US
Mailing Address - Phone:260-438-0496
Mailing Address - Fax:
Practice Address - Street 1:1529 UNION ST APT A
Practice Address - Street 2:
Practice Address - City:ALAMEDA
Practice Address - State:CA
Practice Address - Zip Code:94501-2681
Practice Address - Country:US
Practice Address - Phone:260-438-0496
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-10-31
Last Update Date:2022-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant