Provider Demographics
NPI:1376748285
Name:GARCIA, LISA MARIE (PA)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:MARIE
Last Name:GARCIA
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12073-B TECH ROAD
Mailing Address - Street 2:
Mailing Address - City:SILVER SPRING
Mailing Address - State:MD
Mailing Address - Zip Code:20904
Mailing Address - Country:US
Mailing Address - Phone:301-593-1315
Mailing Address - Fax:
Practice Address - Street 1:12073-B TECH ROAD
Practice Address - Street 2:
Practice Address - City:SILVER SPRING
Practice Address - State:MD
Practice Address - Zip Code:20904
Practice Address - Country:US
Practice Address - Phone:301-593-1315
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-19
Last Update Date:2013-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WYTL#508363A00000X
MDC0004354363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant