Provider Demographics
NPI:1194929216
Name:ALLY, LISA (PA-C)
Entity type:Individual
Prefix:MS
First Name:LISA
Middle Name:
Last Name:ALLY
Suffix:
Gender:F
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 1:1031 N 75TH AVE
Mailing Address - Street 2:
Mailing Address - City:HOLLYWOOD
Mailing Address - State:FL
Mailing Address - Zip Code:33024-5351
Mailing Address - Country:US
Mailing Address - Phone:305-298-3116
Mailing Address - Fax:
Practice Address - Street 1:10205 S DIXIE HWY
Practice Address - Street 2:102
Practice Address - City:PINECREST
Practice Address - State:FL
Practice Address - Zip Code:33156-3167
Practice Address - Country:US
Practice Address - Phone:305-666-0496
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-13
Last Update Date:2010-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA 9103925363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant