Provider Demographics
NPI:1588131254
Name:IWASAKI, LISA
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:IWASAKI
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 1:1701 VIA MONTEMAR
Mailing Address - Street 2:
Mailing Address - City:PALOS VERDES ESTATES
Mailing Address - State:CA
Mailing Address - Zip Code:90274-1257
Mailing Address - Country:US
Mailing Address - Phone:310-339-1657
Mailing Address - Fax:
Practice Address - Street 1:4201 TORRANCE BLVD STE 340
Practice Address - Street 2:
Practice Address - City:TORRANCE
Practice Address - State:CA
Practice Address - Zip Code:90503-4514
Practice Address - Country:US
Practice Address - Phone:310-540-0079
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-30
Last Update Date:2018-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant