Provider Demographics
NPI:1912196981
Name:ORTIZ DE PRYOR, LISSETTE (PA-C)
Entity type:Individual
Prefix:
First Name:LISSETTE
Middle Name:
Last Name:ORTIZ DE PRYOR
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:LISSETTE
Other - Middle Name:
Other - Last Name:ORTIZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:331 NEWMAN SPRINGS RD
Mailing Address - Street 2:BLDG 2, STE 220
Mailing Address - City:RED BANK
Mailing Address - State:NJ
Mailing Address - Zip Code:07701-5688
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1 RIVERVIEW PLZ
Practice Address - Street 2:
Practice Address - City:RED BANK
Practice Address - State:NJ
Practice Address - Zip Code:07701-1864
Practice Address - Country:US
Practice Address - Phone:732-741-2700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-10-16
Last Update Date:2025-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MP00186200363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant