Healthcare Provider Details

I. General information

NPI: 1588905236
Provider Name (Legal Business Name): LISA CHRISTINE GAVIN KUCERA F.N.P.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: LISA CHRISTINE GAVIN

II. Dates (important events)

Enumeration Date: 03/05/2013
Last Update Date: 08/12/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2485 HOSPITAL DR STE 321
MOUNTAIN VIEW CA
94040-4103
US

IV. Provider business mailing address

2485 HOSPITAL DR STE 321
MOUNTAIN VIEW CA
94040-4103
US

V. Phone/Fax

Practice location:
  • Phone: 650-988-7830
  • Fax:
Mailing address:
  • Phone: 650-988-7830
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number22920
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: