Provider Demographics
NPI:1285901645
Name:OCQUE, LISA D
Entity type:Individual
Prefix:MRS
First Name:LISA
Middle Name:D
Last Name:OCQUE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7279 PEAR TREE MDWS
Mailing Address - Street 2:
Mailing Address - City:ONTARIO
Mailing Address - State:NY
Mailing Address - Zip Code:14519-9618
Mailing Address - Country:US
Mailing Address - Phone:315-576-0646
Mailing Address - Fax:
Practice Address - Street 1:7279 PEAR TREE MDWS
Practice Address - Street 2:
Practice Address - City:ONTARIO
Practice Address - State:NY
Practice Address - Zip Code:14519-9618
Practice Address - Country:US
Practice Address - Phone:315-576-0646
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-29
Last Update Date:2011-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY011267-1174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY1740332444Medicaid