MEDICARE: DR. LISA MARIE MICAN PHARM.D.

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	1835P1300X	Psychiatric Pharmacist	39245	TX

General Provider Information

NPI Number	:	1932106424
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. LISA MARIE MICAN PHARM.D.

Provider Business Mailing Address
First Line	:	4110 GUADALUPE ST
Second Line	:
City	:	AUSTIN
State	:	TX
Zip	:	78751-4223
Country	:	US
Telephone Number	:	512-419-2757
Fax Number	:	512-419-2788

Provider Business Practice Location Address
First Line	:	4110 GUADALUPE ST
Second Line	:
City	:	AUSTIN
State	:	TX
Zip	:	78751-4223
Country	:	US
Telephone Number	:	512-419-2757
Fax Number	:	512-419-2788

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

Provider Enumeration Date	:	06/30/2005
Last Update Date	:	12/02/2015

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