Provider Demographics
NPI:1063466373
Name:DEZELAN, LISA C (PA)
Entity Type:Individual
Prefix:MS
First Name:LISA
Middle Name:C
Last Name:DEZELAN
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:9200 W WISCONSIN AVE
Mailing Address - Street 2:DIVISION OF NEOPLASTIC DISEASES
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53226-3522
Mailing Address - Country:US
Mailing Address - Phone:414-805-6800
Mailing Address - Fax:414-805-6805
Practice Address - Street 1:9200 W WISCONSIN AVE
Practice Address - Street 2:DIVISION OF NEOPLASTIC DISEASES
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53226-3522
Practice Address - Country:US
Practice Address - Phone:414-805-6800
Practice Address - Fax:414-805-6805
Is Sole Proprietor?:No
Enumeration Date:2006-05-20
Last Update Date:2012-12-13
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WI1458363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
005000261HOtherHUMANA
WI1063466373Medicaid
0005G73601Medicare ID - Type Unspecified
P56681Medicare UPIN