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General NPI Number Information
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NPI Number | 1942654132
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Entity Type | Individual
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Provider Name | LISA MA
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Gender | Female
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Dates
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Enumeration Date | 04/14/2016
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Last Update Date | 06/14/2022
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Provider Practice Location Address
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Address Line | 622 W 168TH ST
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City | NEW YORK
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State | NY
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Zip | 10032-3720
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Country | US
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Telephone | 212-342-5525
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Fax |
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Provider Business Mailing Address
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Address Line | 24 SYCAMORE WAY
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City | WARREN
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State | NJ
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Zip | 07059-5674
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Country | US
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Telephone |
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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 | 207L00000X
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Taxonomy Name | Anesthesiology Physician
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License Number | 25MA11125300
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License Number State | NJ
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