Provider Demographics
NPI:1245367358
Name:O'CONNOR, LISA ROBYN (PT)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:ROBYN
Last Name:O'CONNOR
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 8125
Mailing Address - Street 2:
Mailing Address - City:FOUNTAIN VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92728-8125
Mailing Address - Country:US
Mailing Address - Phone:650-965-8434
Mailing Address - Fax:650-965-8545
Practice Address - Street 1:1235 PEAR AVE
Practice Address - Street 2:# 101
Practice Address - City:MOUNTAIN VIEW
Practice Address - State:CA
Practice Address - Zip Code:94043-1444
Practice Address - Country:US
Practice Address - Phone:650-965-8434
Practice Address - Fax:650-965-8545
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-27
Last Update Date:2007-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT33223204C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes204C00000XAllopathic & Osteopathic PhysiciansNeuromusculoskeletal Medicine, Sports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPT33223OtherSTATE LICENSE
CAOPT332230Medicare PIN