Basic Information
| Provider Information | |||||||||
| NPI: | 1619391182 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ROGERS | ||||||||
| FirstName: | LISA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | PHYSICIAN ASSISTANT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 31581 CANYON ESTATES DR | ||||||||
| Address2: | |||||||||
| City: | LAKE ELSINORE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 925320424 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9512443500 | ||||||||
| FaxNumber: | 9512443535 | ||||||||
| Practice Location | |||||||||
| Address1: | 565 N MOUNT VERNON AVE | ||||||||
| Address2: | |||||||||
| City: | SAN BERNARDINO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 924112661 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9098849091 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/05/2014 | ||||||||
| LastUpdateDate: | 12/23/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 12/23/2019 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA51334 | CA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.