Provider Demographics
NPI:1164949350
Name:LISBOA, LIVIA DE SOUZA (MS, PA-C)
Entity Type:Individual
Prefix:
First Name:LIVIA
Middle Name:DE SOUZA
Last Name:LISBOA
Suffix:
Gender:F
Credentials:MS, PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2650 WARRENVILLE RD STE 280
Mailing Address - Street 2:
Mailing Address - City:DOWNERS GROVE
Mailing Address - State:IL
Mailing Address - Zip Code:60515-2075
Mailing Address - Country:US
Mailing Address - Phone:630-324-7900
Mailing Address - Fax:
Practice Address - Street 1:2650 WARRENVILLE RD STE 280
Practice Address - Street 2:
Practice Address - City:DOWNERS GROVE
Practice Address - State:IL
Practice Address - Zip Code:60515-2075
Practice Address - Country:US
Practice Address - Phone:630-324-7900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-28
Last Update Date:2023-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085006328363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1144532OtherNCCPA
IL085006328OtherILLINOIS DEPARTMENT OF FINANCIAL AND PROFESSIONAL REGULATION