Provider Demographics
NPI:1316453616
Name:RIZZO, LISA N (PA)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:N
Last Name:RIZZO
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2300 N EDWARD ST STE 6102
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:IL
Mailing Address - Zip Code:62526-4163
Mailing Address - Country:US
Mailing Address - Phone:217-876-2857
Mailing Address - Fax:
Practice Address - Street 1:3131 N WATER ST
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:IL
Practice Address - Zip Code:62526-2472
Practice Address - Country:US
Practice Address - Phone:217-876-5320
Practice Address - Fax:217-876-5865
Is Sole Proprietor?:No
Enumeration Date:2017-12-21
Last Update Date:2017-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085006450363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant