Basic Information
| Provider Information | |||||||||
| NPI: | 1841203726 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | COCO | ||||||||
| FirstName: | LISA | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | N.P. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 211 S 9TH ST | ||||||||
| Address2: | SUITE 600 | ||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191076810 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2159551925 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 211 S 9TH ST | ||||||||
| Address2: | V | ||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191076810 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2159551925 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/14/2006 | ||||||||
| LastUpdateDate: | 03/26/2014 | ||||||||
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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 | 26NJ00004700 | NJ | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363L00000X | VP007017B | PA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 102881837 | 05 | PA | MEDICAID |