Provider Demographics
NPI:1487031100
Name:PHAN, LISE (MD)
Entity Type:Individual
Prefix:
First Name:LISE
Middle Name:
Last Name:PHAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1015 N 1ST AVE
Mailing Address - Street 2:SUITE B
Mailing Address - City:ARCADIA
Mailing Address - State:CA
Mailing Address - Zip Code:91006
Mailing Address - Country:US
Mailing Address - Phone:626-598-3770
Mailing Address - Fax:626-598-3797
Practice Address - Street 1:1015 N 1ST AVE
Practice Address - Street 2:SUITE B
Practice Address - City:ARCADIA
Practice Address - State:CA
Practice Address - Zip Code:91006
Practice Address - Country:US
Practice Address - Phone:626-598-3770
Practice Address - Fax:626-598-3770
Is Sole Proprietor?:No
Enumeration Date:2015-05-01
Last Update Date:2024-02-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTMED-PHYS-LIC-857822084N0400X
CAA1478232084N0600X, 2084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
No2084N0600XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyClinical Neurophysiology