Basic Information
| Provider Information | |||||||||
| NPI: | 1003264110 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GU | ||||||||
| FirstName: | LISA | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 845347 | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752845347 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4692913369 | ||||||||
| FaxNumber: | 2146450078 | ||||||||
| Practice Location | |||||||||
| Address1: | 5323 HARRY HINES BLVD | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 753900001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2146486400 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/31/2016 | ||||||||
| LastUpdateDate: | 09/09/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/09/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | ME144492 | FL | N | Allopathic & Osteopathic Physicians | Anesthesiology | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 207L00000X | T0220 | TX | Y | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 106777400 | 05 | FL | MEDICAID |