1972833994 NPI number — LISA RENEE SUN

Table of content: LISA RENEE SUN (NPI 1972833994)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1972833994 NPI number — LISA RENEE SUN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SUN
Provider First Name:
LISA
Provider Middle Name:
RENEE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1972833994
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/20/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
200 N. WOLFE STREET
Provider Second Line Business Mailing Address:
SUITE 2158
Provider Business Mailing Address City Name:
BALTIMORE
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
21287
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
410-955-4259
Provider Business Mailing Address Fax Number:
410-614-2297

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1800 ORLEANS ST
Provider Second Line Business Practice Location Address:
ROOM 8444
Provider Business Practice Location Address City Name:
BALTIMORE
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
21287-0010
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
908-246-8237
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/14/2010

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 2084N0402X , with the licence number:  D81690 , registered in the state of MD ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: D81690 . This is a "STATE LICENSE" identifier , issued by the state of ( MD ) . This identifiers is of the category "OTHER".




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