Basic Information
| Provider Information | |||||||||
| NPI: | 1972540599 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DAVIS | ||||||||
| FirstName: | LISA | ||||||||
| MiddleName: | ANN | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | PA-C | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | HOLLAND | ||||||||
| OtherFirstName: | LISA | ||||||||
| OtherMiddleName: | ANN | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | PA-C | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 2970 HILLTOP MALL RD | ||||||||
| Address2: | STE #203 | ||||||||
| City: | RICHMOND | ||||||||
| State: | CA | ||||||||
| PostalCode: | 948061947 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5102228000 | ||||||||
| FaxNumber: | 5102222690 | ||||||||
| Practice Location | |||||||||
| Address1: | 2970 HILLTOP MALL RD | ||||||||
| Address2: | STE #203 | ||||||||
| City: | RICHMOND | ||||||||
| State: | CA | ||||||||
| PostalCode: | 948061947 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5102228000 | ||||||||
| FaxNumber: | 5102222690 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/01/2006 | ||||||||
| LastUpdateDate: | 01/05/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA18325 | CA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.