Provider Demographics
NPI:1245647486
Name:CRUZ, LISSETTE I (PA-C)
Entity type:Individual
Prefix:MRS
First Name:LISSETTE
Middle Name:I
Last Name:CRUZ
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:259 LIGHT ST
Mailing Address - Street 2:
Mailing Address - City:STRATFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06614-5233
Mailing Address - Country:US
Mailing Address - Phone:203-583-5976
Mailing Address - Fax:
Practice Address - Street 1:64 BLACK ROCK AVE
Practice Address - Street 2:
Practice Address - City:BRIDGEPORT
Practice Address - State:CT
Practice Address - Zip Code:06605-1200
Practice Address - Country:US
Practice Address - Phone:203-579-5000
Practice Address - Fax:203-579-5113
Is Sole Proprietor?:No
Enumeration Date:2014-07-21
Last Update Date:2015-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT003107363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant