Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 207QA0401X | Family Doctor - Addiction Medicine | MD060721-L | PA |
Y | 208200000X | Surgeon | 25MA06954000 | NJ |
Y | 208600000X | Surgeon | 25MA06954000 | NJ |
N | 208200000X | Surgeon | 51460 | KY |
N | 208600000X | Surgeon | 51460 | KY |
N | 208200000X | Surgeon | MD060721L | PA |
N | 208600000X | Surgeon | MD060721L | PA |
NPI | 1467451823 |
---|---|
Provider Name | Lisa Ann Medvetz |
First Address | Haddon Heights, NJ 08035-1761 |
Second Address | Willingboro, NJ 08046-1103 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 19/07/2005 |
Last Update Date | 18/07/2019 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
0017932090008 | (05) | PA |
113499 | BCBS (01) | PA |
8239606 | (05) | NJ |
H16617 | (02) |