Healthcare Provider Details

I. General information

NPI: 1164087482
Provider Name (Legal Business Name): LISA CHUONG
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/02/2019
Last Update Date: 04/23/2026
Certification Date: 04/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4301 X ST
SACRAMENTO CA
95817-2214
US

IV. Provider business mailing address

4301 X ST
SACRAMENTO CA
95817-2214
US

V. Phone/Fax

Practice location:
  • Phone: 916-734-2011
  • Fax:
Mailing address:
  • Phone: 916-734-2011
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number0110010808
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA031611
License Number StateDC
# 3
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberC0009744
License Number StateMD
# 4
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA67097
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: