Provider Demographics
NPI:1679085047
Name:SMITH, LISA
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:SMITH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 727
Mailing Address - Street 2:
Mailing Address - City:SONOITA
Mailing Address - State:AZ
Mailing Address - Zip Code:85637-0727
Mailing Address - Country:US
Mailing Address - Phone:307-272-4815
Mailing Address - Fax:
Practice Address - Street 1:NINE 14TH AVE WEST
Practice Address - Street 2:
Practice Address - City:POLSON
Practice Address - State:MT
Practice Address - Zip Code:59860-5321
Practice Address - Country:US
Practice Address - Phone:406-883-4378
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-10-25
Last Update Date:2017-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ11516A225200000X
MT13146225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ2A05978680OtherARIZONA FINGER PRINT CLEARANCE CARD