MEDICARE: MS. MONA LIZA LASIAN

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	225100000X	Physical Therapist	30244	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	30244	OTHER	CA	PT LICENSE NUMBER

General Provider Information

NPI Number	:	1942742846
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. MONA LIZA LASIAN

Provider Business Mailing Address
First Line	:	3516 ELM AVE APT 305
Second Line	:
City	:	LONG BEACH
State	:	CA
Zip	:	90807-3915
Country	:	US
Telephone Number	:	562-338-0495
Fax Number	:

Provider Business Practice Location Address
First Line	:	3516 ELM AVE APT 305
Second Line	:
City	:	LONG BEACH
State	:	CA
Zip	:	90807-3915
Country	:	US
Telephone Number	:	562-338-0495
Fax Number	:

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

Provider Enumeration Date	:	11/08/2016
Last Update Date	:	11/08/2016

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