Healthcare Provider Details

I. General information

NPI: 1023473055
Provider Name (Legal Business Name): LISA BRUSH NP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/17/2015
Last Update Date: 12/17/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

489 5TH ST
GUSTINE CA
95322-1514
US

IV. Provider business mailing address

12573 SYCAMORE AVE
PATTERSON CA
95363-9263
US

V. Phone/Fax

Practice location:
  • Phone: 209-854-3728
  • Fax:
Mailing address:
  • Phone: 209-480-7861
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberNP95003518
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: