Individual
LISA MARIE TOLLIVER
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
PA-C
Contact information
Practice address
6276 COUNTY ROAD 107, PROCTORVILLE, OH 45669-8867
(888) 221-1826
Mailing address
PO BOX 390, HUNTINGTON, WV 25708-0390
(304) 429-1088
(304) 696-1623
Taxonomy
Speciality
Code
Description
License number
State
363AM0700X
Medical Physician Assistant
2555
WV
363AM0700X
Medical Physician Assistant
50.003489
OH
363AM0700X
Medical Physician Assistant
Primary
PA1634
KY
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
0166746
—
OH
05
—
1043598485
—
WV
05
—
7100179880
—
KY
01
—
P01094323
RR MEDICARE
KY
Enumeration date
08/03/2011
Last updated
11/10/2021
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