Provider Demographics
NPI:1205184470
Name:BUSH, LISA (PA-C)
Entity Type:Individual
Prefix:MS
First Name:LISA
Middle Name:
Last Name:BUSH
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MS
Other - First Name:LISA
Other - Middle Name:
Other - Last Name:PROTES-BUSH
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PA-C
Mailing Address - Street 1:5151 STATE UNIVERSITY DR
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90032-4226
Mailing Address - Country:US
Mailing Address - Phone:310-343-3319
Mailing Address - Fax:323-343-3304
Practice Address - Street 1:5151 STATE UNIVERSITY DR
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90032-4226
Practice Address - Country:US
Practice Address - Phone:323-343-3319
Practice Address - Fax:323-343-3304
Is Sole Proprietor?:No
Enumeration Date:2012-08-20
Last Update Date:2012-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA11201363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant