Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207Q00000X | Family Doctor | 95013410 | CA |
NPI | 1003455742 |
---|---|
Provider Name | Lisa Kristine Mizeur |
First Address | Weed, CA 96094-9644 |
Second Address | Weed, CA 96094-9400 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 28/12/2019 |
Last Update Date | 28/12/2019 |