Provider Demographics
NPI:1972937514
Name:REZAC, LISA MARGARET (PHYSICIAN ASSISTANT)
Entity Type:Individual
Prefix:MRS
First Name:LISA
Middle Name:MARGARET
Last Name:REZAC
Suffix:
Gender:F
Credentials:PHYSICIAN ASSISTANT
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Mailing Address - Street 1:3541 W BRADDOCK RD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:ALEXANDRIA
Mailing Address - State:VA
Mailing Address - Zip Code:22302-1915
Mailing Address - Country:US
Mailing Address - Phone:703-379-6020
Mailing Address - Fax:
Practice Address - Street 1:3541 W BRADDOCK RD
Practice Address - Street 2:SUITE 101
Practice Address - City:ALEXANDRIA
Practice Address - State:VA
Practice Address - Zip Code:22302-1915
Practice Address - Country:US
Practice Address - Phone:703-379-6020
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-08-31
Last Update Date:2013-08-31
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
VA0110004133363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant