Provider Demographics
NPI:1760434377
Name:HOFMAN, LISA (RD)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:HOFMAN
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:
Other - Last Name:TRACY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:600 COFFEE RD
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95355-4201
Mailing Address - Country:US
Mailing Address - Phone:209-524-1211
Mailing Address - Fax:
Practice Address - Street 1:1700 MCHENRY AVE
Practice Address - Street 2:SUITE #60 B
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95350-4373
Practice Address - Country:US
Practice Address - Phone:209-548-7860
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-16
Last Update Date:2008-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA896740133N00000X, 133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
No133N00000XDietary & Nutritional Service ProvidersNutritionist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ32391ZMedicare ID - Type UnspecifiedMEDICARE NUMBER
CAQ34453Medicare UPIN