Provider Demographics
NPI:1619448735
Name:PORADZISZ, LISA
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:PORADZISZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10012 CALUMET AVE STE A
Mailing Address - Street 2:
Mailing Address - City:MUNSTER
Mailing Address - State:IN
Mailing Address - Zip Code:46321-4055
Mailing Address - Country:US
Mailing Address - Phone:219-227-5119
Mailing Address - Fax:
Practice Address - Street 1:10012 CALUMET AVE STE A
Practice Address - Street 2:
Practice Address - City:MUNSTER
Practice Address - State:IN
Practice Address - Zip Code:46321-4055
Practice Address - Country:US
Practice Address - Phone:219-227-5119
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-12-16
Last Update Date:2018-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71008611A363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily