Provider Demographics
NPI:1144013616
Name:BANUELOS, LISA M (NP)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:M
Last Name:BANUELOS
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1318 THRASHER WAY
Mailing Address - Street 2:
Mailing Address - City:SUISUN CITY
Mailing Address - State:CA
Mailing Address - Zip Code:94585-3019
Mailing Address - Country:US
Mailing Address - Phone:707-246-9954
Mailing Address - Fax:
Practice Address - Street 1:100 HOSPITAL DR FL 2
Practice Address - Street 2:
Practice Address - City:VALLEJO
Practice Address - State:CA
Practice Address - Zip Code:94589-2580
Practice Address - Country:US
Practice Address - Phone:707-427-4900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-05-27
Last Update Date:2025-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95290679363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care