Provider Demographics
NPI:1245684489
Name:SIINO, LISA ANN MAZZOCUT (DO)
Entity type:Individual
Prefix:DR
First Name:LISA
Middle Name:ANN MAZZOCUT
Last Name:SIINO
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:ANN
Other - Last Name:MAZZOCUT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1801 W CHESTNUT AVE
Mailing Address - Street 2:
Mailing Address - City:YAKIMA
Mailing Address - State:WA
Mailing Address - Zip Code:98902-3805
Mailing Address - Country:US
Mailing Address - Phone:510-316-4255
Mailing Address - Fax:
Practice Address - Street 1:15 82ND DR STE 100
Practice Address - Street 2:
Practice Address - City:GLADSTONE
Practice Address - State:OR
Practice Address - Zip Code:97027-2550
Practice Address - Country:US
Practice Address - Phone:510-316-4255
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-13
Last Update Date:2023-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
ORDO211433204D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes204D00000XAllopathic & Osteopathic PhysiciansNeuromusculoskeletal Medicine & OMMGroup - Single Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program