Healthcare Provider Details

I. General information

NPI: 1962873042
Provider Name (Legal Business Name): LISA ANNETTE O'BRIEN PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/14/2015
Last Update Date: 02/20/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1215 EAST MICHIGAN AVENUE SPARROW HOSPITAL, DIVISION OF NEONATOLOGY
LANSING MI
48912
US

IV. Provider business mailing address

804 SERVICE RD STE A109F
EAST LANSING MI
48824-7015
US

V. Phone/Fax

Practice location:
  • Phone: 517-364-2670
  • Fax:
Mailing address:
  • Phone: 517-884-2976
  • Fax: 517-432-3928

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number5601003345
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: