Provider Demographics
NPI:1750787156
Name:DENG, LISA (AGPCNP)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:DENG
Suffix:
Gender:F
Credentials:AGPCNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1241 JOHNSON AVE # 322
Mailing Address - Street 2:
Mailing Address - City:SAN LUIS OBISPO
Mailing Address - State:CA
Mailing Address - Zip Code:93401-3306
Mailing Address - Country:US
Mailing Address - Phone:805-242-4455
Mailing Address - Fax:805-542-9589
Practice Address - Street 1:1551 BISHOP ST STE 310
Practice Address - Street 2:
Practice Address - City:SAN LUIS OBISPO
Practice Address - State:CA
Practice Address - Zip Code:93401-4637
Practice Address - Country:US
Practice Address - Phone:805-242-4455
Practice Address - Fax:805-542-9589
Is Sole Proprietor?:No
Enumeration Date:2014-11-12
Last Update Date:2016-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95001507363L00000X, 363LA2200X, 363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACB228110Medicare PIN