Provider Demographics
NPI:1457986168
Name:LIRA, MARITZA J (AGNP)
Entity Type:Individual
Prefix:
First Name:MARITZA
Middle Name:J
Last Name:LIRA
Suffix:
Gender:F
Credentials:AGNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:28120 PEACOCK RIDGE DR APT 704
Mailing Address - Street 2:
Mailing Address - City:RANCHO PALOS VERDES
Mailing Address - State:CA
Mailing Address - Zip Code:90275-3400
Mailing Address - Country:US
Mailing Address - Phone:949-735-2586
Mailing Address - Fax:949-334-0215
Practice Address - Street 1:28120 PEACOCK RIDGE DR APT 704
Practice Address - Street 2:
Practice Address - City:RANCHO PALOS VERDES
Practice Address - State:CA
Practice Address - Zip Code:90275-3400
Practice Address - Country:US
Practice Address - Phone:949-735-2586
Practice Address - Fax:949-334-0215
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-03
Last Update Date:2022-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95014079363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontologyGroup - Single Specialty