Healthcare Provider Details

I. General information

NPI: 1003050667
Provider Name (Legal Business Name): LISA MARIE SPROWL M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/27/2009
Last Update Date: 09/28/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4400 DUCKHORN DRIVE SUITE 100
SACRAMENTO CA
95834
US

IV. Provider business mailing address

3400 DATA DRIVE PHYSICIAN SUPPORT SERVICES
RANCHO CORDOVA CA
95670-7956
US

V. Phone/Fax

Practice location:
  • Phone: 916-575-8000
  • Fax: 916-575-8099
Mailing address:
  • Phone: 916-379-2948
  • Fax: 916-858-7065

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberA113285
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: