Provider Demographics
NPI:1922213594
Name:MATHERSON, LISA JO (CRNP)
Entity type:Individual
Prefix:MRS
First Name:LISA
Middle Name:JO
Last Name:MATHERSON
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:271 GREEN HOLLOW RD
Mailing Address - Street 2:
Mailing Address - City:GLENMOORE
Mailing Address - State:PA
Mailing Address - Zip Code:19343-1509
Mailing Address - Country:US
Mailing Address - Phone:610-913-8008
Mailing Address - Fax:610-913-8007
Practice Address - Street 1:2050 OLD WEST CHESTER PIKE
Practice Address - Street 2:
Practice Address - City:HAVERTOWN
Practice Address - State:PA
Practice Address - Zip Code:19083-2712
Practice Address - Country:US
Practice Address - Phone:610-449-8600
Practice Address - Fax:610-449-1302
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASPOO3533H363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology