Provider Demographics
NPI:1316065717
Name:ESPARZA, LISA ANGELA (LAC,MASTERS, BS)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:ANGELA
Last Name:ESPARZA
Suffix:
Gender:F
Credentials:LAC,MASTERS, BS
Other - Prefix:MRS
Other - First Name:LISA
Other - Middle Name:ANGELA
Other - Last Name:WAGENSEIL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MASTER, BS LAC
Mailing Address - Street 1:PO BOX 1840
Mailing Address - Street 2:
Mailing Address - City:PISMO BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:93448-1840
Mailing Address - Country:US
Mailing Address - Phone:805-710-6526
Mailing Address - Fax:805-481-5893
Practice Address - Street 1:1010 E GRAND AVE
Practice Address - Street 2:
Practice Address - City:ARROYO GRANDE
Practice Address - State:CA
Practice Address - Zip Code:93420-2505
Practice Address - Country:US
Practice Address - Phone:805-710-6526
Practice Address - Fax:805-481-5893
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC11534171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA171100000XOtherACUPUNCTURIST