Provider Demographics
NPI:1053517011
Name:WAUGH, LISA ANN (LMT)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:ANN
Last Name:WAUGH
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2939 SHADYSIDE RD
Mailing Address - Street 2:
Mailing Address - City:ST ALBANS
Mailing Address - State:WV
Mailing Address - Zip Code:25177
Mailing Address - Country:US
Mailing Address - Phone:304-610-7888
Mailing Address - Fax:
Practice Address - Street 1:1109 JEFFERSON RD
Practice Address - Street 2:
Practice Address - City:S CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25309-9780
Practice Address - Country:US
Practice Address - Phone:304-610-7888
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV0388204C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes204C00000XAllopathic & Osteopathic PhysiciansNeuromusculoskeletal Medicine, Sports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0388OtherLICENSE