Individual
LISA RAE INNIS
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
P.A-C
Contact information
Practice address
75 SYLVANIA DR, BEAVERCREEK, OH 45440-3237
(937) 320-5050
(937) 320-5060
Mailing address
75 SYLVANIA DR, BEAVERCREEK, OH 45440-3237
(937) 320-5050
(937) 320-2060
Taxonomy
Speciality
Code
Description
License number
State
363A00000X
Physician Assistant
Primary
50.001303RX
OH
363A00000X
Physician Assistant
PA17447
CA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
0385986
—
OH
Enumeration date
10/02/2006
Last updated
08/24/2020
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