MEDICARE: LISA PARK

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208600000X	Surgery Physician	57.027085	OH
2	208C00000X	Colon & Rectal Surgery Physician	A168789	CA

General Provider Information

NPI Number	:	1568857142
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LISA PARK

Provider Business Mailing Address
First Line	:	5 BON AIR RD STE 101
Second Line	:
City	:	LARKSPUR
State	:	CA
Zip	:	94939-1134
Country	:	US
Telephone Number	:	415-924-2515
Fax Number	:

Provider Business Practice Location Address
First Line	:	5 BON AIR RD STE 101
Second Line	:
City	:	LARKSPUR
State	:	CA
Zip	:	94939-1134
Country	:	US
Telephone Number	:	415-924-2515
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/01/2015
Last Update Date	:	12/03/2021

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Directions to “ LISA PARK ” Practice Location

Language	Start Address	Practice Location

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