Provider Demographics
NPI:1841788320
Name:HARRISON, LISA MICHELLE (DPM)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:MICHELLE
Last Name:HARRISON
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3000 COLBY ST STE 104
Mailing Address - Street 2:
Mailing Address - City:BERKELEY
Mailing Address - State:CA
Mailing Address - Zip Code:94705-2090
Mailing Address - Country:US
Mailing Address - Phone:510-849-3800
Mailing Address - Fax:510-849-3810
Practice Address - Street 1:3000 COLBY ST STE 104
Practice Address - Street 2:
Practice Address - City:BERKELEY
Practice Address - State:CA
Practice Address - Zip Code:94705-2090
Practice Address - Country:US
Practice Address - Phone:510-849-3800
Practice Address - Fax:510-849-3810
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-30
Last Update Date:2021-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CAE5798213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program