Provider Demographics
NPI:1306263199
Name:SHOTYK, LISA ANN (AGPCNP-BC)
Entity type:Individual
Prefix:MRS
First Name:LISA
Middle Name:ANN
Last Name:SHOTYK
Suffix:
Gender:F
Credentials:AGPCNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21 N KINGSCROFT DR
Mailing Address - Street 2:
Mailing Address - City:BEAR
Mailing Address - State:DE
Mailing Address - Zip Code:19701-1423
Mailing Address - Country:US
Mailing Address - Phone:302-836-8350
Mailing Address - Fax:302-836-1906
Practice Address - Street 1:2600 GLASGOW AVE
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:DE
Practice Address - Zip Code:19702-4773
Practice Address - Country:US
Practice Address - Phone:302-836-8350
Practice Address - Fax:302-836-1906
Is Sole Proprietor?:Yes
Enumeration Date:2014-03-18
Last Update Date:2014-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DELB-0000288363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner