Provider Demographics
NPI:1083699078
Name:DAIMARU-ENOKI, LISSA C (MD)
Entity Type:Individual
Prefix:DR
First Name:LISSA
Middle Name:C
Last Name:DAIMARU-ENOKI
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14406 NE 20TH AVE
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98686-1448
Mailing Address - Country:US
Mailing Address - Phone:360-571-4244
Mailing Address - Fax:360-571-4246
Practice Address - Street 1:14406 NE 20TH AVE
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98686-1448
Practice Address - Country:US
Practice Address - Phone:360-571-4244
Practice Address - Fax:360-571-4246
Is Sole Proprietor?:No
Enumeration Date:2005-12-13
Last Update Date:2022-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ32929207V00000X
WAMD 60170420207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ867103Medicaid
AZ867103Medicaid
82902Medicare ID - Type Unspecified