Healthcare Provider Details

I. General information

NPI: 1396999116
Provider Name (Legal Business Name): LISA GAYE RYAVEC PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/06/2008
Last Update Date: 03/29/2023
Certification Date: 03/24/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1225 N H ST
LOMPOC CA
93436-3301
US

IV. Provider business mailing address

1515 E OCEAN AVE
LOMPOC CA
93436-7092
US

V. Phone/Fax

Practice location:
  • Phone: 805-737-8700
  • Fax: 805-737-8701
Mailing address:
  • Phone: 805-737-8700
  • Fax: 805-737-8701

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number9101141
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number13982
License Number StateCA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier9101141
Identifier TypeOTHER
Identifier StateFL
Identifier IssuerSTATE LICENSE
# 2
Identifier13982
Identifier TypeOTHER
Identifier StateCA
Identifier IssuerSTATE LICENSE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: