Provider Demographics
NPI:1114498342
Name:VAN-LE, LISA
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:VAN-LE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:625 E BIG BEAVER RD STE 200
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:MI
Mailing Address - Zip Code:48083-1434
Mailing Address - Country:US
Mailing Address - Phone:586-863-4000
Mailing Address - Fax:
Practice Address - Street 1:625 E BIG BEAVER RD STE 200
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:MI
Practice Address - Zip Code:48083-1434
Practice Address - Country:US
Practice Address - Phone:586-863-4000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-12-16
Last Update Date:2023-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601009430363A00000X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant