MEDICARE: LISA VAZ

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2255A2300X	Athletic Trainer

General Provider Information

NPI Number	:	1700435518
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LISA VAZ

Provider Business Mailing Address
First Line	:	2335 MONUMENT RD
Second Line	:
City	:	MYERSVILLE
State	:	MD
Zip	:	21773-8511
Country	:	US
Telephone Number	:	301-293-3189
Fax Number	:

Provider Business Practice Location Address
First Line	:	1595 BOWIS DR
Second Line	:
City	:	POINT OF ROCKS
State	:	MD
Zip	:	21777-2098
Country	:	US
Telephone Number	:	304-860-9022
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/05/2019
Last Update Date	:	09/05/2019

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Directions to “ LISA VAZ ” Practice Location

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