Provider Demographics
NPI:1124343272
Name:JIN, LISA MARIE (PA)
Entity type:Individual
Prefix:MRS
First Name:LISA
Middle Name:MARIE
Last Name:JIN
Suffix:
Gender:F
Credentials:PA
Other - Prefix:MRS
Other - First Name:LISA
Other - Middle Name:MARIE
Other - Last Name:CANTOR
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PA
Mailing Address - Street 1:207 LUMPKIN ST
Mailing Address - Street 2:
Mailing Address - City:FORT MOORE
Mailing Address - State:GA
Mailing Address - Zip Code:31905-6548
Mailing Address - Country:US
Mailing Address - Phone:254-226-0826
Mailing Address - Fax:
Practice Address - Street 1:9040 JACKSON AVE
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98431-2705
Practice Address - Country:US
Practice Address - Phone:253-968-2252
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-04-01
Last Update Date:2024-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171000000XOther Service ProvidersMilitary Health Care Provider
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical