Provider Demographics
NPI:1902889629
Name:MATTEI, LISA M (PAC)
Entity type:Individual
Prefix:MRS
First Name:LISA
Middle Name:M
Last Name:MATTEI
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:M
Other - Last Name:YAGIELLO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:100 N ACADEMY AVE
Mailing Address - Street 2:
Mailing Address - City:DANVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:17822-4903
Mailing Address - Country:US
Mailing Address - Phone:570-271-6144
Mailing Address - Fax:570-271-6578
Practice Address - Street 1:1155 E MOUNTAIN BLVD
Practice Address - Street 2:
Practice Address - City:WILKES BARRE
Practice Address - State:PA
Practice Address - Zip Code:18702-7906
Practice Address - Country:US
Practice Address - Phone:570-808-5135
Practice Address - Fax:570-808-5136
Is Sole Proprietor?:No
Enumeration Date:2005-11-28
Last Update Date:2020-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOA000886363A00000X
PAAO000886363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
086137NBAMedicare ID - Type Unspecified