Provider Demographics
NPI:1033397450
Name:MESAROS, LISA A (PA-C)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:A
Last Name:MESAROS
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:A
Other - Last Name:NICHOLAS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 3360
Mailing Address - Street 2:PMG SW WA
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97208-3360
Mailing Address - Country:US
Mailing Address - Phone:866-747-2455
Mailing Address - Fax:
Practice Address - Street 1:931 S MARKET BLVD
Practice Address - Street 2:PMG SW WA CHEHALIS FAMILY MEDICINE
Practice Address - City:CHEHALIS
Practice Address - State:WA
Practice Address - Zip Code:98532-3423
Practice Address - Country:US
Practice Address - Phone:360-767-6300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-02-07
Last Update Date:2014-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC0002085363AM0700X
WAPA60125666363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical