Provider Demographics
NPI:1669452405
Name:LISS, LAHNA G (PA-C)
Entity type:Individual
Prefix:
First Name:LAHNA
Middle Name:G
Last Name:LISS
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:LAHNA
Other - Middle Name:G
Other - Last Name:LEES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:2900 CORPORATE WAY
Mailing Address - Street 2:MPG DOOR D
Mailing Address - City:MIRAMAR
Mailing Address - State:FL
Mailing Address - Zip Code:33025-3925
Mailing Address - Country:US
Mailing Address - Phone:954-276-5581
Mailing Address - Fax:954-985-7074
Practice Address - Street 1:601 N FLAMINGO RD
Practice Address - Street 2:SUITE 409
Practice Address - City:PEMBROKE PINES
Practice Address - State:FL
Practice Address - Zip Code:33028-1015
Practice Address - Country:US
Practice Address - Phone:954-844-4480
Practice Address - Fax:954-447-5344
Is Sole Proprietor?:No
Enumeration Date:2006-01-18
Last Update Date:2014-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA3542363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL290682100Medicaid
FLE3315ZMedicare PIN
FLE3315YMedicare PIN
S93546Medicare UPIN