Provider Demographics
NPI:1568770725
Name:PERALTA, LISETTE (PA-C)
Entity Type:Individual
Prefix:
First Name:LISETTE
Middle Name:
Last Name:PERALTA
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:609 HOWARD AVE APT 110
Mailing Address - Street 2:
Mailing Address - City:MONTEBELLO
Mailing Address - State:CA
Mailing Address - Zip Code:90640-6918
Mailing Address - Country:US
Mailing Address - Phone:562-706-0345
Mailing Address - Fax:
Practice Address - Street 1:12401 WASHINGTON BLVD
Practice Address - Street 2:
Practice Address - City:WHITTIER
Practice Address - State:CA
Practice Address - Zip Code:90602-1006
Practice Address - Country:US
Practice Address - Phone:562-706-0345
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-09-21
Last Update Date:2010-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA20974363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant