=====================================================
General NPI Number Information
=====================================================
NPI Number | 1114069259
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SVETLANA ALEXANDER LISOVSKIY P.A.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/13/2007
-----------------------------------------------------
Last Update Date | 03/18/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3944 RANCH ROAD 620 S STE 100
-----------------------------------------------------
City | BEE CAVE
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78738-7000
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 512-580-5775
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3944 RANCH ROAD 620 S STE 100
-----------------------------------------------------
City | BEE CAVE
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78738-7000
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 512-580-5775
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363AM0700X
-----------------------------------------------------
Taxonomy Name | Medical Physician Assistant
-----------------------------------------------------
License Number | PA19053
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------