Healthcare Provider Details

I. General information

NPI: 1649538034
Provider Name (Legal Business Name): LISA A FLYNN PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/24/2012
Last Update Date: 03/08/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5701 S HOOVER ST
LOS ANGELES CA
90037-4045
US

IV. Provider business mailing address

808 W 58TH ST
LOS ANGELES CA
90037-3632
US

V. Phone/Fax

Practice location:
  • Phone: 323-541-1400
  • Fax: 323-541-1401
Mailing address:
  • Phone: 323-541-1400
  • Fax: 323-541-1401

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA22193
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: