Provider Demographics
NPI:1578972543
Name:BURSCH, LISA (NURSE PRACTITIONER)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:BURSCH
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:41162 MESA ROBLES CIR
Mailing Address - Street 2:
Mailing Address - City:TEMECULA
Mailing Address - State:CA
Mailing Address - Zip Code:92592-9326
Mailing Address - Country:US
Mailing Address - Phone:951-313-7976
Mailing Address - Fax:
Practice Address - Street 1:7777 MILLIKEN AVE STE 360
Practice Address - Street 2:
Practice Address - City:RANCHO CUCAMONGA
Practice Address - State:CA
Practice Address - Zip Code:91730-6782
Practice Address - Country:US
Practice Address - Phone:909-944-7099
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-08-04
Last Update Date:2019-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA472262363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics