Provider Demographics
NPI:1851679674
Name:MARK, LISA SUSAN
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:SUSAN
Last Name:MARK
Suffix:
Gender:F
Credentials:
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 31309
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90031-0309
Mailing Address - Country:US
Mailing Address - Phone:323-865-3105
Mailing Address - Fax:
Practice Address - Street 1:1441 EASTLAKE AVE
Practice Address - Street 2:NOR 8302E
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90089-0112
Practice Address - Country:US
Practice Address - Phone:323-865-3000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-27
Last Update Date:2016-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA12333363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0100430OtherGROUP MEDICAL
CAW18762OtherGROUP MEDICARE
CA1902846306OtherGROUP NPI