Provider Demographics
NPI:1134513385
Name:LU, ELISE PETERSON
Entity type:Individual
Prefix:
First Name:ELISE
Middle Name:PETERSON
Last Name:LU
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:ELISE
Other - Middle Name:BRIANNE
Other - Last Name:PETERSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4401 PENN AVE FL 3
Mailing Address - Street 2:
Mailing Address - City:PITTSBURGH
Mailing Address - State:PA
Mailing Address - Zip Code:15224-1334
Mailing Address - Country:US
Mailing Address - Phone:412-692-5135
Mailing Address - Fax:
Practice Address - Street 1:4401 PENN AVE
Practice Address - Street 2:AOB SUITE 5400
Practice Address - City:PITTSBURGH
Practice Address - State:PA
Practice Address - Zip Code:15224
Practice Address - Country:US
Practice Address - Phone:412-692-5285
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-03-26
Last Update Date:2018-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
PAMD463652208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program