Provider Demographics
NPI:1366447138
Name:MOLIN, LISA JUNE
Entity Type:Individual
Prefix:DR
First Name:LISA
Middle Name:JUNE
Last Name:MOLIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:901 OAK PARK BLVD STE 202
Mailing Address - Street 2:
Mailing Address - City:PISMO BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:93449-3410
Mailing Address - Country:US
Mailing Address - Phone:805-481-1368
Mailing Address - Fax:805-481-8013
Practice Address - Street 1:1555 HIGUERA ST
Practice Address - Street 2:
Practice Address - City:SAN LUIS OBISPO
Practice Address - State:CA
Practice Address - Zip Code:93401-2917
Practice Address - Country:US
Practice Address - Phone:805-541-2368
Practice Address - Fax:805-541-2553
Is Sole Proprietor?:No
Enumeration Date:2005-06-16
Last Update Date:2023-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA55137174400000X, 207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAH16740Medicare UPIN