Healthcare Provider Details

I. General information

NPI: 1174845846
Provider Name (Legal Business Name): LISA KOTZEN PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: LISA JOHNIDES JOHNIDES

II. Dates (important events)

Enumeration Date: 02/23/2010
Last Update Date: 01/22/2021
Certification Date: 01/22/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3555 W 13 MILE RD STE N120
ROYAL OAK MI
48073-6710
US

IV. Provider business mailing address

26901 BEAUMONT BLVD STE 3D
SOUTHFIELD MI
48033-3849
US

V. Phone/Fax

Practice location:
  • Phone: 855-863-8761
  • Fax: 248-551-2301
Mailing address:
  • Phone:
  • Fax: 947-522-0307

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number5601005577
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: