Provider Demographics
NPI:1629511175
Name:STATZ, LISA R (PA-C)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:R
Last Name:STATZ
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 1:441 STUART ST
Mailing Address - Street 2:#404
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02116-5019
Mailing Address - Country:US
Mailing Address - Phone:857-317-2057
Mailing Address - Fax:
Practice Address - Street 1:441 STUART ST
Practice Address - Street 2:#404
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02116-5019
Practice Address - Country:US
Practice Address - Phone:857-317-2057
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-11-30
Last Update Date:2016-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA5985207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology