Provider Demographics
NPI:1609843192
Name:CERVANTES, LISA L (PAC)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:L
Last Name:CERVANTES
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1004 GARFIELD ST
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53711-2156
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1004 GARFIELD ST
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53711-2156
Practice Address - Country:US
Practice Address - Phone:000-000-0000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-02
Last Update Date:2023-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI990363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant