Provider Demographics
NPI:1114069259
Name:LISOVSKIY, SVETLANA ALEXANDER (PA)
Entity Type:Individual
Prefix:MRS
First Name:SVETLANA
Middle Name:ALEXANDER
Last Name:LISOVSKIY
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2425 EAST ST STE 15
Mailing Address - Street 2:
Mailing Address - City:CONCORD
Mailing Address - State:CA
Mailing Address - Zip Code:94520-1926
Mailing Address - Country:US
Mailing Address - Phone:925-682-9232
Mailing Address - Fax:925-682-1120
Practice Address - Street 1:2425 EAST ST STE 15
Practice Address - Street 2:
Practice Address - City:CONCORD
Practice Address - State:CA
Practice Address - Zip Code:94520-1926
Practice Address - Country:US
Practice Address - Phone:925-682-9232
Practice Address - Fax:925-682-1120
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA19053363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical