Provider Demographics
NPI:1750433546
Name:VASANTH, LISA (MD)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:VASANTH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 873010
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98687-3010
Mailing Address - Country:US
Mailing Address - Phone:360-882-2778
Mailing Address - Fax:360-604-1730
Practice Address - Street 1:700 NE 87TH AVE # 330
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98664-1913
Practice Address - Country:US
Practice Address - Phone:360-882-2778
Practice Address - Fax:360-604-1730
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-18
Last Update Date:2016-04-13
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY222188207RR0500X
WAMD60631890207RR0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYA400000629Medicare PIN