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General NPI Number Information
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NPI Number | 1801349774
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Entity Type | Individual
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Provider Name | LISA MICHELLE KOTLER PA-C
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Gender | Female
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Dates
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Enumeration Date | 07/27/2016
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Last Update Date | 05/19/2021
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Provider Practice Location Address
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Address Line | 1040 W IMPERIAL HWY
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City | LA HABRA
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State | CA
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Zip | 90631-0608
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Country | US
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Telephone | 715-451-1072
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Fax | 714-451-1078
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Provider Business Mailing Address
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Address Line | 2403 RALSTON LN
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City | REDONDO BEACH
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State | CA
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Zip | 90278-5121
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Country | US
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Telephone | 484-574-1011
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363AM0700X
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Taxonomy Name | Medical Physician Assistant
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License Number | C5-0001080
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License Number State | DE
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Taxonomy #2
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number | 59311
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License Number State | CA
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