Healthcare Provider Details

I. General information

NPI: 1750433546
Provider Name (Legal Business Name): LISA VASANTH MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/18/2007
Last Update Date: 04/13/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

700 NE 87TH AVE # 330
VANCOUVER WA
98664-1913
US

IV. Provider business mailing address

PO BOX 873010
VANCOUVER WA
98687-3010
US

V. Phone/Fax

Practice location:
  • Phone: 360-882-2778
  • Fax: 360-604-1730
Mailing address:
  • Phone: 360-882-2778
  • Fax: 360-604-1730

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RR0500X
TaxonomyRheumatology Physician
License Number222188
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code207RR0500X
TaxonomyRheumatology Physician
License NumberMD60631890
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: