Provider Demographics
NPI:1801349774
Name:KOTLER, LISA MICHELLE (PA-C)
Entity type:Individual
Prefix:MRS
First Name:LISA
Middle Name:MICHELLE
Last Name:KOTLER
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2403 RALSTON LN
Mailing Address - Street 2:
Mailing Address - City:REDONDO BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90278-5121
Mailing Address - Country:US
Mailing Address - Phone:484-574-1011
Mailing Address - Fax:
Practice Address - Street 1:1040 W IMPERIAL HWY
Practice Address - Street 2:
Practice Address - City:LA HABRA
Practice Address - State:CA
Practice Address - Zip Code:90631-0608
Practice Address - Country:US
Practice Address - Phone:715-451-1072
Practice Address - Fax:714-451-1078
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-27
Last Update Date:2021-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEC5-0001080363AM0700X
CA59311363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical