Basic Information
| Provider Information | |||||||||
| NPI: | 1134513385 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LU | ||||||||
| FirstName: | ELISE | ||||||||
| MiddleName: | PETERSON | ||||||||
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| OtherOrganizationName: | |||||||||
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| OtherLastName: | PETERSON | ||||||||
| OtherFirstName: | ELISE | ||||||||
| OtherMiddleName: | BRIANNE | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 4401 PENN AVE FL 3 | ||||||||
| Address2: | |||||||||
| City: | PITTSBURGH | ||||||||
| State: | PA | ||||||||
| PostalCode: | 152241334 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4126925135 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 4401 PENN AVE | ||||||||
| Address2: | AOB SUITE 5400 | ||||||||
| City: | PITTSBURGH | ||||||||
| State: | PA | ||||||||
| PostalCode: | 15224 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4126925285 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/26/2015 | ||||||||
| LastUpdateDate: | 06/27/2018 | ||||||||
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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 | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 208000000X | MD463652 | PA | Y | Allopathic & Osteopathic Physicians | Pediatrics |
No ID Information.