Provider Demographics
NPI:1477678977
Name:OWEN, LISA A (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:LISA
Middle Name:A
Last Name:OWEN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:A
Other - Last Name:GRANGER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:23181 VERDUGO DR STE 103A
Mailing Address - Street 2:
Mailing Address - City:LAGUNA HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:92653-1313
Mailing Address - Country:US
Mailing Address - Phone:949-366-1053
Mailing Address - Fax:
Practice Address - Street 1:23181 VERDUGO DR STE 103A
Practice Address - Street 2:
Practice Address - City:LAGUNA HILLS
Practice Address - State:CA
Practice Address - Zip Code:92653-1313
Practice Address - Country:US
Practice Address - Phone:949-366-1053
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-21
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA13418363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAP82958Medicare UPIN