Provider Demographics
NPI:1124467816
Name:WAYNICK, LISA KATHRYN (PA)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:KATHRYN
Last Name:WAYNICK
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:KATHRYN
Other - Last Name:REILE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:529 HELENE AVE
Mailing Address - Street 2:
Mailing Address - City:ROYAL OAK
Mailing Address - State:MI
Mailing Address - Zip Code:48067-3980
Mailing Address - Country:US
Mailing Address - Phone:248-770-1531
Mailing Address - Fax:
Practice Address - Street 1:2799 W GRAND BLVD
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48202-2608
Practice Address - Country:US
Practice Address - Phone:313-916-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-06-17
Last Update Date:2021-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601006673363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant