Provider Demographics
NPI:1912196981
Name:ORTIZ DE PRYOR, LISSETTE (PA-C)
Entity Type:Individual
Prefix:
First Name:LISSETTE
Middle Name:
Last Name:ORTIZ DE PRYOR
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:LISSETTE
Other - Middle Name:
Other - Last Name:ORTIZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:3100 SPRING FOREST RD
Mailing Address - Street 2:STE 130
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27616-2880
Mailing Address - Country:US
Mailing Address - Phone:919-882-0706
Mailing Address - Fax:919-873-9821
Practice Address - Street 1:321 N WARREN ST
Practice Address - Street 2:HENRY J AUSTIN HEALTH CENTER INC
Practice Address - City:TRENTON
Practice Address - State:NJ
Practice Address - Zip Code:08618-4741
Practice Address - Country:US
Practice Address - Phone:609-278-5939
Practice Address - Fax:609-695-3532
Is Sole Proprietor?:No
Enumeration Date:2007-10-16
Last Update Date:2017-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MP00186200363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant