Provider Demographics
NPI:1154419117
Name:BRAZIL, LISA (CFNP)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:BRAZIL
Suffix:
Gender:F
Credentials:CFNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:35 CASA ST STE 320
Mailing Address - Street 2:
Mailing Address - City:SAN LUIS OBISPO
Mailing Address - State:CA
Mailing Address - Zip Code:93405-1894
Mailing Address - Country:US
Mailing Address - Phone:805-250-4844
Mailing Address - Fax:057-850-3568
Practice Address - Street 1:35 CASA ST STE 320
Practice Address - Street 2:
Practice Address - City:SAN LUIS OBISPO
Practice Address - State:CA
Practice Address - Zip Code:93405
Practice Address - Country:US
Practice Address - Phone:805-250-4844
Practice Address - Fax:057-850-3568
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-11
Last Update Date:2019-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMR34090207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM53704533Medicaid