Provider Demographics
NPI:1982095410
Name:BEVINS, LISA (PM)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:BEVINS
Suffix:
Gender:F
Credentials:PM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8991 NW 67TH CT
Mailing Address - Street 2:
Mailing Address - City:TAMARAC
Mailing Address - State:FL
Mailing Address - Zip Code:33321-3605
Mailing Address - Country:US
Mailing Address - Phone:954-605-2586
Mailing Address - Fax:
Practice Address - Street 1:111 JIM MORAN BLVD
Practice Address - Street 2:
Practice Address - City:DEERFIELD BEACH
Practice Address - State:FL
Practice Address - Zip Code:33442-1701
Practice Address - Country:US
Practice Address - Phone:954-426-2418
Practice Address - Fax:954-429-2489
Is Sole Proprietor?:No
Enumeration Date:2015-02-05
Last Update Date:2015-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLJA11573146L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes146L00000XEmergency Medical Service ProvidersEmergency Medical Technician, Paramedic