Provider Demographics
NPI:1033114160
Name:MAESTAS, LISA P (DO)
Entity Type:Individual
Prefix:DR
First Name:LISA
Middle Name:P
Last Name:MAESTAS
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:P
Other - Last Name:BERLE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:PO BOX 3649
Mailing Address - Street 2:
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99220-3649
Mailing Address - Country:US
Mailing Address - Phone:509-755-6580
Mailing Address - Fax:509-755-6580
Practice Address - Street 1:12410 E SINTO AVE STE B
Practice Address - Street 2:
Practice Address - City:SPOKANE VALLEY
Practice Address - State:WA
Practice Address - Zip Code:99216-2280
Practice Address - Country:US
Practice Address - Phone:509-838-2531
Practice Address - Fax:509-755-6580
Is Sole Proprietor?:No
Enumeration Date:2005-06-15
Last Update Date:2014-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOP604558162085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM881327OtherAHCCCS
NMNM004A63OtherBLUESHIELD/NM
NM10013148OtherLOVELACE HEALTHPLAN
NM39626253Medicaid
NM2222574OtherFIRST HEALTH
NM39626253Medicaid
NM343429200Medicare PIN