Provider Demographics
NPI:1689812257
Name:THACKWELL, LISA J (PA-C)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:J
Last Name:THACKWELL
Suffix:
Gender:F
Credentials:PA-C
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Mailing Address - Street 1:960 E GREEN ST
Mailing Address - Street 2:SUITE 292
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91106-2412
Mailing Address - Country:US
Mailing Address - Phone:626-449-4494
Mailing Address - Fax:626-449-4474
Practice Address - Street 1:4190 E WOODMEN RD STE 100
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80920-8075
Practice Address - Country:US
Practice Address - Phone:719-632-4455
Practice Address - Fax:360-462-5181
Is Sole Proprietor?:No
Enumeration Date:2009-02-04
Last Update Date:2022-11-30
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
CAPA22118363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant