Basic Information
| Provider Information | |||||||||
| NPI: | 1902412505 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MAI | ||||||||
| FirstName: | LISA | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7 VARENNES ST APT 4 | ||||||||
| Address2: | |||||||||
| City: | SAN FRANCISCO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 941333420 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4159632486 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2700 NW STEWART PKWY | ||||||||
| Address2: | |||||||||
| City: | ROSEBURG | ||||||||
| State: | OR | ||||||||
| PostalCode: | 974711214 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5416730611 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/18/2020 | ||||||||
| LastUpdateDate: | 09/18/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/18/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.