Provider Demographics
NPI:1386692101
Name:MINER, LISA (PAC)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:MINER
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11410 NE 124TH ST # PM702
Mailing Address - Street 2:
Mailing Address - City:KIRKLAND
Mailing Address - State:WA
Mailing Address - Zip Code:98034-4305
Mailing Address - Country:US
Mailing Address - Phone:425-434-1500
Mailing Address - Fax:425-977-9485
Practice Address - Street 1:13317 NE 175TH ST STE N
Practice Address - Street 2:
Practice Address - City:WOODINVILLE
Practice Address - State:WA
Practice Address - Zip Code:98072-3517
Practice Address - Country:US
Practice Address - Phone:425-434-1500
Practice Address - Fax:425-977-9485
Is Sole Proprietor?:No
Enumeration Date:2006-05-04
Last Update Date:2021-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA10004081363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAP43310Medicare UPIN
P00121619Medicare PIN
WAAB28481Medicare PIN