Provider Demographics
NPI:1811363690
Name:MEZA, LISA (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:LISA
Middle Name:
Last Name:MEZA
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:E23970 POW WOW TRAIL
Mailing Address - Street 2:
Mailing Address - City:WATERSMEET
Mailing Address - State:MI
Mailing Address - Zip Code:49969
Mailing Address - Country:US
Mailing Address - Phone:906-358-4587
Mailing Address - Fax:906-358-4118
Practice Address - Street 1:E23970 POW WOW TRAIL
Practice Address - Street 2:
Practice Address - City:WATERSMEET
Practice Address - State:MI
Practice Address - Zip Code:49969
Practice Address - Country:US
Practice Address - Phone:906-358-4587
Practice Address - Fax:906-358-4118
Is Sole Proprietor?:No
Enumeration Date:2015-08-17
Last Update Date:2015-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601007437363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant