Provider Demographics
NPI:1912686791
Name:LAC, LISA
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:LAC
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1880 N ORANGE GROVE AVE
Mailing Address - Street 2:
Mailing Address - City:POMONA
Mailing Address - State:CA
Mailing Address - Zip Code:91767-3006
Mailing Address - Country:US
Mailing Address - Phone:909-623-2100
Mailing Address - Fax:
Practice Address - Street 1:1880 N ORANGE GROVE AVE
Practice Address - Street 2:
Practice Address - City:POMONA
Practice Address - State:CA
Practice Address - Zip Code:91767-3006
Practice Address - Country:US
Practice Address - Phone:909-623-2100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-18
Last Update Date:2025-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant