Lisa Laura Wall, PA

Primary specialty

Physician AssistantTaxonomy code 363A00000X

Practice address

3755 7TH Ter Ste 101
Vero Beach, FL 32960-6531

Phone

(772) 569-5056

Fax

(772) 562-5098

NPI assigned

Sep 12, 2008

Sex

Female

Sole proprietor

Yes

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 2

Addresses

Other identifiers 2

Other names 1

• Lisa Laura Guida Former name

Medicare fee-for-service enrollment

Enrolled in FL

Eligible to order & refer

• Part B services: Yes
• Medical equipment: Yes
• Home health: Yes
• Power mobility devices: Yes
• Hospice: No

Green means eligible to order or refer.

Enrollment records 1

Specialty

Physician Assistant

Education

Other, 2000

Medicare assignment

Accepts the Medicare-approved amount as payment in full

Group practices

Leavitt Medical Associates of Florida IncGroup PAC ID 4688579311, 199 clinicians

Practice addresses (Care Compare)

Medicare enrollment (NPD)

Enrolled

Credentials

Physician Assistant

Practice roles

Locations

Networks

• Freedom Health HMO Network
• Optimum HealthCare HMO Network

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.

• Leavitt Medical Associates of Florida Inc

  dba Advanced Dermatology and Cosmetic Surq

  • Dermatology Physician
  • Sebastian, FL
  • NPI 1083872535
  Medicare reassignment Care Compare group NPD
• Leavitt Medical Associates of Florida Inc

  dba Advanced Dermatology and Cosmetic Surgery

  • Dermatology Physician
  • St Petersburg, FL
  • NPI 1679731178
  NPD
• Leavitt Medical Associates of Florida Inc

  dba Advanced Dermatology and Cosmetic Surgery

  • Dermatology Physician
  • Orlando, FL
  • NPI 1316105885
  NPD (past)
• Leavitt Medical Associates of Florida Inc

  dba Advanced Dermatology And Cosmetic Surgery

  • Dermatology Physician
  • Heathrow, FL
  • NPI 1528097284
  NPD (past)
• NJ Certified Dermatology PC

  • Dermatology Physician
  • Neptune, NJ
  • NPI 1003263807
  NPD (past)

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1221177600000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1710288000000",
    "number": "1205085321",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "151 SOUTHHALL LN STE 300",
            "city": "MAITLAND",
            "state": "FL",
            "postal_code": "327517172",
            "telephone_number": "407-875-2080",
            "fax_number": "407-650-3455"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "3755 7TH TER STE 101",
            "city": "VERO BEACH",
            "state": "FL",
            "postal_code": "329606531",
            "telephone_number": "772-569-5056",
            "fax_number": "772-562-5098"
        }
    ],
    "practiceLocations": [
        {
            "address_1": "484 US Highway 1 Ste C",
            "address_purpose": "LOCATION",
            "city": "Sebastian",
            "state": "FL",
            "postal_code": "329588454",
            "country_code": "US",
            "telephone_number": "772-646-6100",
            "fax_number": "772-646-6110",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "basic": {
        "last_name": "WALL",
        "first_name": "LISA",
        "middle_name": "LAURA",
        "name_prefix": "Mrs.",
        "credential": "PA",
        "sole_proprietor": "YES",
        "sex": "F",
        "enumeration_date": "2008-09-12",
        "last_updated": "2024-03-13",
        "certification_date": "2024-03-13",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "363A00000X",
            "taxonomy_group": "",
            "desc": "Physician Assistant",
            "state": "NJ",
            "license": "25MP00107400",
            "primary": false
        },
        {
            "code": "363A00000X",
            "taxonomy_group": "",
            "desc": "Physician Assistant",
            "state": "FL",
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "MEDICARE PTAN",
            "identifier": "IM816Z",
            "state": "FL"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "017124100",
            "state": "FL"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "first_name": "LISA",
            "last_name": "GUIDA",
            "middle_name": "LAURA",
            "credential": "PA",
            "code": "1",
            "type": "Former Name"
        }
    ]
}

• Walgreen Co (Walgreens #04642)
• Walgreen Co (Walgreens #03607)
• Walgreen Co (Walgreens #01127)
• Kelly Elizabeth Walker, LMT
• Odane Walker
• Cynthia Catherine Wallace, P.A.
• Wilson King Wallace, MD
• Conor Walsh, PHARMD
• Laura Leigh Walsh, PA
• Piper Walsh, LMHC

• Physician Assistant in Vero Beach, FL
• Providers in Vero Beach, FL by specialty
• Physician Assistant in Florida

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Mar 13, 2024; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring.
• Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.