Healthcare Provider Details

I. General information

NPI: 1457303182
Provider Name (Legal Business Name): LISA PEREZ P.A.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/17/2006
Last Update Date: 12/04/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

ONE HEALTHY WAY SOUTH NASSAU COMMUNITIES HOSPITAL
OCEANSIDE NY
11572
US

IV. Provider business mailing address

1 HEALTHY WAY ATT: PHYSICIAN BILLING-CREDENTAILS
OCEANSIDE NY
11572-1551
US

V. Phone/Fax

Practice location:
  • Phone: 516-374-8631
  • Fax:
Mailing address:
  • Phone: 516-255-1616
  • Fax: 516-255-4672

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number010479
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: