Healthcare Provider Details

I. General information

NPI: 1528078326
Provider Name (Legal Business Name): LIZA T ESCAMILLA PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/08/2006
Last Update Date: 10/31/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 MICHIGAN ST NE
GRAND RAPIDS MI
49503-2560
US

IV. Provider business mailing address

2537 MOMENTUM PL
CHICAGO IL
60689-5325
US

V. Phone/Fax

Practice location:
  • Phone: 616-391-1680
  • Fax:
Mailing address:
  • Phone: 616-975-1845
  • Fax: 616-285-0846

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number5601004823
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number004823
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: