Healthcare Provider Details

I. General information

NPI: 1801349774
Provider Name (Legal Business Name): LISA MICHELLE KOTLER PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/27/2016
Last Update Date: 05/19/2021
Certification Date: 05/18/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1040 W IMPERIAL HWY
LA HABRA CA
90631-0608
US

IV. Provider business mailing address

2403 RALSTON LN
REDONDO BEACH CA
90278-5121
US

V. Phone/Fax

Practice location:
  • Phone: 715-451-1072
  • Fax: 714-451-1078
Mailing address:
  • Phone: 484-574-1011
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberC5-0001080
License Number StateDE
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number59311
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: