Healthcare Provider Details

I. General information

NPI: 1821142738
Provider Name (Legal Business Name): LISA D ZYLSTRA PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: LISA M DEKKER

II. Dates (important events)

Enumeration Date: 01/22/2007
Last Update Date: 01/21/2022
Certification Date: 01/21/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

406 SE 131ST AVE STE C305
VANCOUVER WA
98683-4004
US

IV. Provider business mailing address

24015 NE W H GARNER RD
YACOLT WA
98675-4303
US

V. Phone/Fax

Practice location:
  • Phone: 360-816-0277
  • Fax: 360-567-4004
Mailing address:
  • Phone: 360-823-8084
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA10004703
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: