Provider Demographics
NPI:1972833994
Name:SUN, LISA RENEE
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:RENEE
Last Name:SUN
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 1:200 N. WOLFE STREET
Mailing Address - Street 2:SUITE 2158
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21287
Mailing Address - Country:US
Mailing Address - Phone:410-955-4259
Mailing Address - Fax:410-614-2297
Practice Address - Street 1:1800 ORLEANS ST
Practice Address - Street 2:ROOM 8444
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21287-0010
Practice Address - Country:US
Practice Address - Phone:908-246-8237
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-01-14
Last Update Date:2018-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD816902084N0402X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0402XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology with Special Qualifications in Child Neurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDD81690OtherSTATE LICENSE