1669452405 NPI number — LAHNA G LISS PA-C

Table of content: LAHNA G LISS PA-C (NPI 1669452405)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1669452405 NPI number — LAHNA G LISS PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LISS
Provider First Name:
LAHNA
Provider Middle Name:
G
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PA-C
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
LEES
Provider Other First Name:
LAHNA
Provider Other Middle Name:
G
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
PA-C
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1669452405
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/29/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2900 CORPORATE WAY
Provider Second Line Business Mailing Address:
MPG DOOR D
Provider Business Mailing Address City Name:
MIRAMAR
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33025-3925
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
954-276-5581
Provider Business Mailing Address Fax Number:
954-985-7074

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
601 N FLAMINGO RD
Provider Second Line Business Practice Location Address:
SUITE 409
Provider Business Practice Location Address City Name:
PEMBROKE PINES
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33028-1015
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
954-844-4480
Provider Business Practice Location Address Fax Number:
954-447-5344
Provider Enumeration Date:
01/18/2006

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: 363A00000X , with the licence number:  PA3542 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 290682100 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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