Provider Demographics
NPI:1447218789
Name:BRENIZE, LISA C (PA-C)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:C
Last Name:BRENIZE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:4760 UNION DEPOSIT RD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:HARRISBURG
Mailing Address - State:PA
Mailing Address - Zip Code:17111-3729
Mailing Address - Country:US
Mailing Address - Phone:717-545-9811
Mailing Address - Fax:717-545-9979
Practice Address - Street 1:4760 UNION DEPOSIT RD
Practice Address - Street 2:SUITE 100
Practice Address - City:HARRISBURG
Practice Address - State:PA
Practice Address - Zip Code:17111-3744
Practice Address - Country:US
Practice Address - Phone:717-545-9811
Practice Address - Fax:717-545-9979
Is Sole Proprietor?:No
Enumeration Date:2006-05-03
Last Update Date:2011-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA051112363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAP76491Medicare UPIN
PA64701Medicare PIN