Provider Demographics
NPI:1366445967
Name:LEZAK, JOANNA L (ANP)
Entity Type:Individual
Prefix:
First Name:JOANNA
Middle Name:L
Last Name:LEZAK
Suffix:
Gender:F
Credentials:ANP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1130 NW 22ND AVE
Mailing Address - Street 2:SUITE 110
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97210-2900
Mailing Address - Country:US
Mailing Address - Phone:503-413-3940
Mailing Address - Fax:503-413-1860
Practice Address - Street 1:1130 NW 22ND AVE
Practice Address - Street 2:SUITE 110
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97210-2900
Practice Address - Country:US
Practice Address - Phone:503-413-3940
Practice Address - Fax:503-413-1860
Is Sole Proprietor?:No
Enumeration Date:2005-05-27
Last Update Date:2024-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR200450078NP363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR275455Medicaid
Q-22994Medicare UPIN
OR275455Medicaid