Healthcare Provider Details

I. General information

NPI: 1669617015
Provider Name (Legal Business Name): LISA LIANE DIMODICA PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/12/2008
Last Update Date: 12/12/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

47 SANTA ROSA ST
SAN LUIS OBISPO CA
93405-5816
US

IV. Provider business mailing address

47 SANTA ROSA ST
SAN LUIS OBISPO CA
93405-5816
US

V. Phone/Fax

Practice location:
  • Phone: 805-542-9596
  • Fax:
Mailing address:
  • Phone: 805-542-9596
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA14335
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: