Provider Demographics
NPI:1497832083
Name:CHARLES, LYSA (MD)
Entity Type:Individual
Prefix:DR
First Name:LYSA
Middle Name:
Last Name:CHARLES
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:2101 E JEFFERSON ST PPQA MEDICARE COMPLIANCE UNT 6 WEST
Mailing Address - Street 2:KAISER PERMANENTE MID ATLANTIC PERMANENTE MEDICAL GROUP
Mailing Address - City:ROCKVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20852-4908
Mailing Address - Country:US
Mailing Address - Phone:301-816-6660
Mailing Address - Fax:301-816-6308
Practice Address - Street 1:2101 E JEFFERSON ST PPQA MEDICARE COMPLIANCE UNT 6 WEST
Practice Address - Street 2:KAISER PERMANENTE MID ATLANTIC PERMANENTE MEDICAL GROUP
Practice Address - City:ROCKVILLE
Practice Address - State:MD
Practice Address - Zip Code:20852-4908
Practice Address - Country:US
Practice Address - Phone:301-816-6660
Practice Address - Fax:301-816-6308
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2021-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0053807207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
F95477Medicare UPIN
K679J999Medicare ID - Type Unspecified