Provider Demographics
NPI:1326489014
Name:NEVITT, LISA MARIE (PA-C)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:MARIE
Last Name:NEVITT
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 RACE ST
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95126-3518
Mailing Address - Country:US
Mailing Address - Phone:408-278-3500
Mailing Address - Fax:408-278-3592
Practice Address - Street 1:455 OCONNOR DR
Practice Address - Street 2:SUITE 150
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95128-1633
Practice Address - Country:US
Practice Address - Phone:408-298-8770
Practice Address - Fax:408-298-8710
Is Sole Proprietor?:No
Enumeration Date:2013-07-10
Last Update Date:2014-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA22923363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant