Provider Demographics
NPI:1144353327
Name:DANIELS, LISA M (PA)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:M
Last Name:DANIELS
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:130 SUTTER ST FL 2
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94104-4009
Mailing Address - Country:US
Mailing Address - Phone:415-658-6791
Mailing Address - Fax:
Practice Address - Street 1:2201 E CAMELBACK RD STE 101A
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85016-3495
Practice Address - Country:US
Practice Address - Phone:602-218-4075
Practice Address - Fax:212-867-4353
Is Sole Proprietor?:No
Enumeration Date:2007-03-14
Last Update Date:2018-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085001837363A00000X
SC2254363A00000X
NC0010-04861363A00000X
AZ4361363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
P75092Medicare UPIN
R03226Medicare PIN
K39304Medicare PIN