Provider Demographics
NPI:1922165513
Name:RIBERA, LISA CAROL (PA-C)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:CAROL
Last Name:RIBERA
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:CAROL
Other - Last Name:DELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:PO BOX 1668
Mailing Address - Street 2:
Mailing Address - City:SHELTON
Mailing Address - State:WA
Mailing Address - Zip Code:98584-5001
Mailing Address - Country:US
Mailing Address - Phone:360-427-9549
Mailing Address - Fax:360-462-2500
Practice Address - Street 1:1701 N 13TH ST
Practice Address - Street 2:
Practice Address - City:SHELTON
Practice Address - State:WA
Practice Address - Zip Code:98584-2077
Practice Address - Country:US
Practice Address - Phone:360-426-2653
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-02
Last Update Date:2023-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA10005025363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAPA10005025OtherPA-C STATE LICENSE
WA8477416Medicaid
WAPA10005025OtherPA-C STATE LICENSE
WA8477416Medicaid