Basic Information
| Provider Information | |||||||||
| NPI: | 1568857142 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PARK | ||||||||
| FirstName: | LISA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5 BON AIR RD STE 101 | ||||||||
| Address2: | |||||||||
| City: | LARKSPUR | ||||||||
| State: | CA | ||||||||
| PostalCode: | 949391134 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4159242515 | ||||||||
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| Practice Location | |||||||||
| Address1: | 5 BON AIR RD STE 101 | ||||||||
| Address2: | |||||||||
| City: | LARKSPUR | ||||||||
| State: | CA | ||||||||
| PostalCode: | 949391134 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4159242515 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/01/2015 | ||||||||
| LastUpdateDate: | 12/03/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 12/03/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | 57.027085 | OH | N | Allopathic & Osteopathic Physicians | Surgery | 208C00000X | A168789 | CA | Y | Allopathic & Osteopathic Physicians | Colon & Rectal Surgery |
No ID Information.