Individual
LISA M CLEMENS
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
P.A.
Contact information
Practice address
2200 RANDALLIA DR, FORT WAYNE, IN 46805-4638
(260) 373-4000
(260) 482-4442
Mailing address
3640 NEW VISION DRIVE, SUITE A, FORT WAYNE, IN 46845-1717
(260) 482-4440
(260) 482-4442
Taxonomy
Speciality
Code
Description
License number
State
363A00000X
Physician Assistant
Primary
10001224A
IN
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
000000680854
ANTHEM
IN
01
—
P00984506
R.R. MEDICARE
IN
Enumeration date
09/09/2010
Last updated
10/19/2023
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