Provider Demographics
NPI:1134365489
Name:ANDERSON, LISSA BROD (MD)
Entity type:Individual
Prefix:DR
First Name:LISSA
Middle Name:BROD
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:LISSA
Other - Middle Name:SIMONE
Other - Last Name:BROD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:1802 YAKIMA AVE
Mailing Address - Street 2:STE 208
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98405-4499
Mailing Address - Country:US
Mailing Address - Phone:253-985-2722
Mailing Address - Fax:253-985-2853
Practice Address - Street 1:1802 YAKIMA AVE
Practice Address - Street 2:STE 208
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98405-4499
Practice Address - Country:US
Practice Address - Phone:253-985-2722
Practice Address - Fax:253-985-2853
Is Sole Proprietor?:No
Enumeration Date:2008-12-16
Last Update Date:2016-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD292112084N0400X
WAMD602223842084N0400X, 2084H0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084H0002XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyHospice and Palliative Medicine
No2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0284389OtherSTATE L&I
WA0284393OtherSTATE L&I
WA0284399OtherSTATE L&I
WA0284399OtherSTATE L&I