Provider Demographics
NPI:1922044403
Name:BRODAK, LISA M (CRNP)
Entity Type:Individual
Prefix:MRS
First Name:LISA
Middle Name:M
Last Name:BRODAK
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:969 GREENTREE RD STE 210
Mailing Address - Street 2:
Mailing Address - City:PITTSBURGH
Mailing Address - State:PA
Mailing Address - Zip Code:15220-3328
Mailing Address - Country:US
Mailing Address - Phone:724-920-8175
Mailing Address - Fax:
Practice Address - Street 1:969 GREENTREE RD STE 210
Practice Address - Street 2:
Practice Address - City:PITTSBURGH
Practice Address - State:PA
Practice Address - Zip Code:15220-3328
Practice Address - Country:US
Practice Address - Phone:724-920-8175
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-21
Last Update Date:2022-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAVP003902B363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
S49712Medicare UPIN
005245LQ6Medicare ID - Type Unspecified