Provider Demographics
NPI:1235967381
Name:PETER, LISA MARIE
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:MARIE
Last Name:PETER
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 1:19700 N 76TH ST APT 2082
Mailing Address - Street 2:
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85255-4594
Mailing Address - Country:US
Mailing Address - Phone:480-601-1085
Mailing Address - Fax:
Practice Address - Street 1:1701 E THOMAS RD # A-104
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85016-7646
Practice Address - Country:US
Practice Address - Phone:602-845-4445
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-22
Last Update Date:2024-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ313055363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily