Provider Demographics
NPI:1841243383
Name:RENSBERGER, LISA A (PA-C)
Entity Type:Individual
Prefix:MS
First Name:LISA
Middle Name:A
Last Name:RENSBERGER
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 25608
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84125-0608
Mailing Address - Country:US
Mailing Address - Phone:206-320-4476
Mailing Address - Fax:206-568-7043
Practice Address - Street 1:751 NE BLAKELY DR STE 3020
Practice Address - Street 2:
Practice Address - City:ISSAQUAH
Practice Address - State:WA
Practice Address - Zip Code:98029
Practice Address - Country:US
Practice Address - Phone:425-313-5345
Practice Address - Fax:425-313-4704
Is Sole Proprietor?:No
Enumeration Date:2006-05-18
Last Update Date:2021-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA10004503363AM0700X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA5366REOtherBLUE SHIELD #
WA8450686Medicaid
WAP00396760OtherRAILROAD MC #
WAP00396760OtherRAILROAD MC #
WA8450686Medicaid