Provider Demographics
NPI:1679531776
Name:PIASTRELLI, LISA MARIE (PAC)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:MARIE
Last Name:PIASTRELLI
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:515 FAIRMOUNT AVE STE 400
Mailing Address - Street 2:
Mailing Address - City:TOWSON
Mailing Address - State:MD
Mailing Address - Zip Code:21286-8518
Mailing Address - Country:US
Mailing Address - Phone:443-471-0472
Mailing Address - Fax:410-584-1882
Practice Address - Street 1:1838 GREENE TREE RD STE 135
Practice Address - Street 2:
Practice Address - City:PIKESVILLE
Practice Address - State:MD
Practice Address - Zip Code:21208-7108
Practice Address - Country:US
Practice Address - Phone:443-471-0472
Practice Address - Fax:410-584-1882
Is Sole Proprietor?:No
Enumeration Date:2006-05-01
Last Update Date:2020-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC0001004363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD444181800Medicaid
MD459449ZR0ZMedicare PIN