Provider Demographics
NPI:1275339244
Name:HA, LILLY
Entity type:Individual
Prefix:
First Name:LILLY
Middle Name:
Last Name:HA
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:171 E 18TH ST APT C1
Mailing Address - Street 2:
Mailing Address - City:COSTA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:92627-3058
Mailing Address - Country:US
Mailing Address - Phone:714-800-9051
Mailing Address - Fax:
Practice Address - Street 1:171 E 18TH ST APT C1
Practice Address - Street 2:
Practice Address - City:COSTA MESA
Practice Address - State:CA
Practice Address - Zip Code:92627-3058
Practice Address - Country:US
Practice Address - Phone:714-800-9051
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-02-20
Last Update Date:2025-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant