Healthcare Provider Details

I. General information

NPI: 1649732769
Provider Name (Legal Business Name): ALEXANDER LISTER DPM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/05/2019
Last Update Date: 07/13/2020
Certification Date: 07/13/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5120 MANZANITA AVE STE 100
CARMICHAEL CA
95608-0590
US

IV. Provider business mailing address

5120 MANZANITA AVE STE 100
CARMICHAEL CA
95608-0590
US

V. Phone/Fax

Practice location:
  • Phone: 916-459-4398
  • Fax:
Mailing address:
  • Phone: 916-705-4135
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License NumberEL6850
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: