Provider Demographics
NPI:1659485886
Name:BAILER, LISA J (PA)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:J
Last Name:BAILER
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:351 HOSPITAL RD
Mailing Address - Street 2:SUITE 401
Mailing Address - City:NEWPORT BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92663-3509
Mailing Address - Country:US
Mailing Address - Phone:949-642-6787
Mailing Address - Fax:949-642-4833
Practice Address - Street 1:351 HOSPITAL RD
Practice Address - Street 2:SUITE 401
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92663-3509
Practice Address - Country:US
Practice Address - Phone:949-642-6787
Practice Address - Fax:949-642-4833
Is Sole Proprietor?:No
Enumeration Date:2006-08-17
Last Update Date:2008-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA17673363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAWPA17673BOtherPTAN
CAWPA17673BMedicare PIN
CAWPA17673BOtherPTAN