Basic Information
| Provider Information | |||||||||
| NPI: | 1326366121 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LISKE | ||||||||
| FirstName: | MICHELLE | ||||||||
| MiddleName: | |||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8765 AERO DR STE 130 | ||||||||
| Address2: | |||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921231767 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8585410181 | ||||||||
| FaxNumber: | 8584300919 | ||||||||
| Practice Location | |||||||||
| Address1: | 4340 GENESEE AVE STE 207 | ||||||||
| Address2: | |||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921174940 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8583565600 | ||||||||
| FaxNumber: | 8583564965 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/04/2010 | ||||||||
| LastUpdateDate: | 10/10/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 10/10/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | G79986 | CA | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
No ID Information.