Provider Demographics
NPI:1720150709
Name:MCDANIEL, LISA (PAC)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:MCDANIEL
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:
Other - Last Name:CLOUSE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 756
Mailing Address - Street 2:
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85299-0756
Mailing Address - Country:US
Mailing Address - Phone:480-355-8525
Mailing Address - Fax:480-355-3115
Practice Address - Street 1:3499 S MERCY RD
Practice Address - Street 2:
Practice Address - City:GILBERT
Practice Address - State:AZ
Practice Address - Zip Code:85297-0437
Practice Address - Country:US
Practice Address - Phone:480-355-8525
Practice Address - Fax:480-355-3115
Is Sole Proprietor?:No
Enumeration Date:2006-11-14
Last Update Date:2013-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ3546363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ3546OtherSTATE LICENSE
AZ031813OtherMEDICARE
AZ031814OtherMEDICARE
AZ031820OtherMEDICARE
AZ183792Medicaid
AZ031815OtherMEDICARE
Q74622Medicare UPIN
AZ031814OtherMEDICARE