Provider Demographics
NPI:1578602298
Name:LANDRY-TAYLOR, LISA MARIE (PA)
Entity Type:Individual
Prefix:MS
First Name:LISA
Middle Name:MARIE
Last Name:LANDRY-TAYLOR
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1642 E CYRENE DR
Mailing Address - Street 2:
Mailing Address - City:CARSON
Mailing Address - State:CA
Mailing Address - Zip Code:90746-2928
Mailing Address - Country:US
Mailing Address - Phone:310-635-4378
Mailing Address - Fax:
Practice Address - Street 1:12021 WILMINGTON AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90059-3019
Practice Address - Country:US
Practice Address - Phone:310-668-5103
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA11431363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant