Provider Demographics
NPI:1063781557
Name:AQUINO, LISA LINDVALL (MD)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:LINDVALL
Last Name:AQUINO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:990 PACIFIC ST
Mailing Address - Street 2:
Mailing Address - City:SAN LUIS OBISPO
Mailing Address - State:CA
Mailing Address - Zip Code:93401-6309
Mailing Address - Country:US
Mailing Address - Phone:805-544-5567
Mailing Address - Fax:805-544-3265
Practice Address - Street 1:990 PACIFIC ST
Practice Address - Street 2:
Practice Address - City:SAN LUIS OBISPO
Practice Address - State:CA
Practice Address - Zip Code:93401-6309
Practice Address - Country:US
Practice Address - Phone:805-544-5567
Practice Address - Fax:805-544-5567
Is Sole Proprietor?:No
Enumeration Date:2011-12-29
Last Update Date:2015-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA106067207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology