Provider Demographics
NPI:1174731574
Name:HALL, LISA C (PA)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:C
Last Name:HALL
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:C
Other - Last Name:MOAK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 468
Mailing Address - Street 2:
Mailing Address - City:BERWICK
Mailing Address - State:PA
Mailing Address - Zip Code:18603-0468
Mailing Address - Country:US
Mailing Address - Phone:610-956-0003
Mailing Address - Fax:
Practice Address - Street 1:1400 S JOYCE ST
Practice Address - Street 2:SUITE 126
Practice Address - City:ARLINGTON
Practice Address - State:VA
Practice Address - Zip Code:22202-1872
Practice Address - Country:US
Practice Address - Phone:703-521-6662
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-18
Last Update Date:2014-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110-002530363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1174731574Medicaid
VA1174731574Medicaid