Provider Demographics
NPI:1225389117
Name:ANDERSEN, LISA M (PAC)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:M
Last Name:ANDERSEN
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
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Mailing Address - Street 1:PO BOX 3699
Mailing Address - Street 2:
Mailing Address - City:NEWPORT BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92659-8699
Mailing Address - Country:US
Mailing Address - Phone:949-574-4638
Mailing Address - Fax:949-574-4680
Practice Address - Street 1:1441 AVACADO AVE
Practice Address - Street 2:503
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92660-7706
Practice Address - Country:US
Practice Address - Phone:949-718-9020
Practice Address - Fax:949-718-9040
Is Sole Proprietor?:No
Enumeration Date:2012-10-02
Last Update Date:2013-11-06
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAPA22548363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical