Healthcare Provider Details

I. General information

NPI: 1467527481
Provider Name (Legal Business Name): LISA TANIMUNE PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/22/2006
Last Update Date: 10/28/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 PARNASSUS AVE MU WEST, MU-405, BOX 0118
SAN FRANCISCO CA
94143-2203
US

IV. Provider business mailing address

500 PARNASSUS AVE MU WEST, MU-405, BOX 0118
SAN FRANCISCO CA
94143-2203
US

V. Phone/Fax

Practice location:
  • Phone: 415-353-1606
  • Fax: 415-353-1312
Mailing address:
  • Phone: 415-353-1606
  • Fax: 415-353-1312

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number1127
License Number StateMA
# 2
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberPA18728
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: