Provider Demographics
NPI:1659313831
Name:TREVAN, LISA (MD)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:TREVAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 7096
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95267-0096
Mailing Address - Country:US
Mailing Address - Phone:209-956-7725
Mailing Address - Fax:209-956-7733
Practice Address - Street 1:10212 GOVERNOR LANE BLVD
Practice Address - Street 2:SUITE1004
Practice Address - City:WILLIAMSPORT
Practice Address - State:MD
Practice Address - Zip Code:21795-4086
Practice Address - Country:US
Practice Address - Phone:301-733-4200
Practice Address - Fax:301-223-7121
Is Sole Proprietor?:No
Enumeration Date:2006-06-12
Last Update Date:2016-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD433370207L00000X
MDD0044644207L00000X, 207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA50090037OtherCAPITAL BC
DCS417 0002OtherCAREFIRST BCBS
MDKBC1CHOtherCAREFIRST BCBS
MDKBC1CHOtherCAREFIRST BCBS
DCS417 0002OtherCAREFIRST BCBS
MD146528Y2MMedicare PIN
F35736Medicare UPIN
MD146528ZVYSMedicare PIN
MD050087028Medicare PIN
PA50090037OtherCAPITAL BC
MDP00745089Medicare PIN