Provider Demographics
NPI:1285785485
Name:WILCOX, LISA WEAR (AUD, CCC-A)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:WEAR
Last Name:WILCOX
Suffix:
Gender:F
Credentials:AUD, CCC-A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4502 MEDICAL DR
Mailing Address - Street 2:HEARING AND BALANCE CENTER
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78229-4402
Mailing Address - Country:US
Mailing Address - Phone:210-358-4583
Mailing Address - Fax:210-358-2654
Practice Address - Street 1:4502 MEDICAL DR
Practice Address - Street 2:HEARING AND BALANCE CENTER
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78229-4402
Practice Address - Country:US
Practice Address - Phone:210-358-4583
Practice Address - Fax:210-358-2654
Is Sole Proprietor?:No
Enumeration Date:2007-01-15
Last Update Date:2009-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHA 01362231H00000X
TX80134231H00000X, 237600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
No237600000XSpeech, Language and Hearing Service ProvidersAudiologist-Hearing Aid Fitter
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHP00434163OtherRRMC
OHPENDINGOtherAETNA
MI5187350Medicaid
OH04709OtherPARAMOUNT
OH296609964-002OtherMMOH
OH296609964-001OtherMMOH
OHPENDINGOtherHEALTH NET TRICARE
OHPENDINGOtherHEALTH NET TRICARE
OHPENDINGMedicare UPIN