Healthcare Provider Details

I. General information

NPI: 1578436366
Provider Name (Legal Business Name): LISA MATSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/26/2025
Last Update Date: 03/03/2026
Certification Date: 03/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

844 OLD TUNNEL RD
GRASS VALLEY CA
95945-8524
US

IV. Provider business mailing address

844 OLD TUNNEL RD
GRASS VALLEY CA
95945-8524
US

V. Phone/Fax

Practice location:
  • Phone: 530-274-9762
  • Fax:
Mailing address:
  • Phone: 530-274-9762
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA67218
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: