Provider Demographics
NPI:1760887376
Name:TORRES, LISA RACHELLE (PA)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:RACHELLE
Last Name:TORRES
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:
Other - Last Name:FOWLES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:8 MEDICAL CENTER RD
Mailing Address - Street 2:
Mailing Address - City:EDGEWOOD
Mailing Address - State:NM
Mailing Address - Zip Code:87015-7086
Mailing Address - Country:US
Mailing Address - Phone:505-281-3406
Mailing Address - Fax:
Practice Address - Street 1:8 MEDICAL CENTER RD
Practice Address - Street 2:
Practice Address - City:EDGEWOOD
Practice Address - State:NM
Practice Address - Zip Code:87015-7086
Practice Address - Country:US
Practice Address - Phone:505-281-3406
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-10-24
Last Update Date:2023-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM134524022363A00000X
NMPA2014-0076363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant