Provider Demographics
NPI:1588698013
Name:WETHERHOLD, LISA MARIE (PA-C)
Entity type:Individual
Prefix:MRS
First Name:LISA
Middle Name:MARIE
Last Name:WETHERHOLD
Suffix:
Gender:F
Credentials:PA-C
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Mailing Address - Street 1:2450 W HUNTING PARK AVE
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19129-1302
Mailing Address - Country:US
Mailing Address - Phone:215-728-6900
Mailing Address - Fax:215-728-5507
Practice Address - Street 1:333 COTTMAN AVE
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19111-2434
Practice Address - Country:US
Practice Address - Phone:215-728-6900
Practice Address - Fax:215-728-5507
Is Sole Proprietor?:No
Enumeration Date:2006-07-10
Last Update Date:2019-03-26
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
PAMA052648363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical