Provider Demographics
NPI:1750413225
Name:DESHOTEL, LISA RENE (PA-C)
Entity type:Individual
Prefix:MRS
First Name:LISA
Middle Name:RENE
Last Name:DESHOTEL
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:102 ISAIAH DR
Mailing Address - Street 2:LAFAYETTE, LA
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70508-5392
Mailing Address - Country:US
Mailing Address - Phone:337-261-5232
Mailing Address - Fax:337-237-5211
Practice Address - Street 1:1602 W PINHOOK RD
Practice Address - Street 2:SUITE 100
Practice Address - City:LAFAYETTE
Practice Address - State:LA
Practice Address - Zip Code:70508-3735
Practice Address - Country:US
Practice Address - Phone:337-234-9925
Practice Address - Fax:337-237-5211
Is Sole Proprietor?:No
Enumeration Date:2007-03-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
LAPA.A 10431RX363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical