Provider Demographics
NPI:1407858111
Name:GLASSER, LISA ILANA (MD)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:ILANA
Last Name:GLASSER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:I
Other - Last Name:WOLF
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:7683 SE 27TH ST
Mailing Address - Street 2:#310
Mailing Address - City:MERCER ISLAND
Mailing Address - State:WA
Mailing Address - Zip Code:98040-2804
Mailing Address - Country:US
Mailing Address - Phone:206-941-9306
Mailing Address - Fax:
Practice Address - Street 1:7683 SE 27TH ST
Practice Address - Street 2:#310
Practice Address - City:MERCER ISLAND
Practice Address - State:WA
Practice Address - Zip Code:98040-2804
Practice Address - Country:US
Practice Address - Phone:206-941-9306
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-12
Last Update Date:2013-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA60322125208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV002018722Medicaid
I11950Medicare UPIN
NV39810Medicare ID - Type UnspecifiedNORIDIAN