Provider Demographics
NPI:1285142125
Name:LAVERTY, LISSANDE MERCEDES (PA-C)
Entity type:Individual
Prefix:
First Name:LISSANDE
Middle Name:MERCEDES
Last Name:LAVERTY
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2375 S MELROSE DR
Mailing Address - Street 2:
Mailing Address - City:VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:92081-8788
Mailing Address - Country:US
Mailing Address - Phone:760-305-1900
Mailing Address - Fax:
Practice Address - Street 1:2375 S MELROSE DR
Practice Address - Street 2:
Practice Address - City:VISTA
Practice Address - State:CA
Practice Address - Zip Code:92081-8788
Practice Address - Country:US
Practice Address - Phone:760-822-9192
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-12
Last Update Date:2023-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program