Basic Information
| Provider Information | |||||||||
| NPI: | 1962675223 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KRANSDORF | ||||||||
| FirstName: | LISA | ||||||||
| MiddleName: | NGUYEN | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | NGUYEN | ||||||||
| OtherFirstName: | LISA | ||||||||
| OtherMiddleName: | THAO | ||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 5767 W CENTURY BLVD STE 400 | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900455631 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3103018732 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 200 MED PLAZA | ||||||||
| Address2: | 365 420 120 | ||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 90024 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3107941276 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/08/2008 | ||||||||
| LastUpdateDate: | 06/10/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 47273 | AZ | N | Allopathic & Osteopathic Physicians | Internal Medicine | 208000000X | A111918 | CA | N | Allopathic & Osteopathic Physicians | Pediatrics | 208000000X | 47273 | AZ | N | Allopathic & Osteopathic Physicians | Pediatrics | 207R00000X | A111918 | CA | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 796979 | 05 | AZ | MEDICAID |