Basic Information
| Provider Information | |||||||||
| NPI: | 1083746887 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ELVIN | ||||||||
| FirstName: | LISA | ||||||||
| MiddleName: | V. | ||||||||
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| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2 BON AIR RD | ||||||||
| Address2: | SUITE 120 | ||||||||
| City: | LARKSPUR | ||||||||
| State: | CA | ||||||||
| PostalCode: | 949391141 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4159275300 | ||||||||
| FaxNumber: | 4159275242 | ||||||||
| Practice Location | |||||||||
| Address1: | 2 BON AIR RD | ||||||||
| Address2: | SUITE 120 | ||||||||
| City: | LARKSPUR | ||||||||
| State: | CA | ||||||||
| PostalCode: | 949391141 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4159275300 | ||||||||
| FaxNumber: | 4159275242 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/09/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 8864 | CA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 382183 | 01 | CA | RN | OTHER | 8864 | 01 | CA | NP | OTHER |