Provider Demographics
NPI:1902412505
Name:MAI, LISA (PA-C)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:MAI
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 1:7 VARENNES ST APT 4
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94133-3420
Mailing Address - Country:US
Mailing Address - Phone:415-963-2486
Mailing Address - Fax:
Practice Address - Street 1:2700 NW STEWART PKWY
Practice Address - Street 2:
Practice Address - City:ROSEBURG
Practice Address - State:OR
Practice Address - Zip Code:97471-1214
Practice Address - Country:US
Practice Address - Phone:541-673-0611
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-18
Last Update Date:2020-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant