Healthcare Provider Details

I. General information

NPI: 1982980645
Provider Name (Legal Business Name): LISSETTE NOVAR PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/26/2011
Last Update Date: 05/24/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

105 NE 3RD ST
FORT LAUDERDALE FL
33301
US

IV. Provider business mailing address

105 NE 3RD ST
FORT LAUDERDALE FL
33301-1046
US

V. Phone/Fax

Practice location:
  • Phone: 754-206-2420
  • Fax: 954-867-5583
Mailing address:
  • Phone: 754-206-2420
  • Fax: 954-867-5583

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number21236
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number9105101
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: