Provider Demographics
NPI:1275511008
Name:MAZUR, LISA C (PAC)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:C
Last Name:MAZUR
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:MRS
Other - First Name:LISA
Other - Middle Name:C
Other - Last Name:MAZUR
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PA C
Mailing Address - Street 1:PO BOX 3048
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:DE
Mailing Address - Zip Code:19804-0048
Mailing Address - Country:US
Mailing Address - Phone:302-224-5678
Mailing Address - Fax:302-224-2848
Practice Address - Street 1:4755 OGLETOWN-STANTON ROAD
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:DE
Practice Address - Zip Code:19718-0001
Practice Address - Country:US
Practice Address - Phone:302-733-1000
Practice Address - Fax:302-733-1633
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEC50000131363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
DE0000756943Medicaid
DE002661D04Medicare ID - Type Unspecified
DE0000756943Medicaid