Provider Demographics
NPI:1063503795
Name:GRISHAM, LISA M (NNP)
Entity Type:Individual
Prefix:MS
First Name:LISA
Middle Name:M
Last Name:GRISHAM
Suffix:
Gender:F
Credentials:NNP
Other - Prefix:MS
Other - First Name:LISA
Other - Middle Name:M
Other - Last Name:MCCOSKEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NNP
Mailing Address - Street 1:2701 E ELVIRA RD
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85756-7214
Mailing Address - Country:US
Mailing Address - Phone:520-626-6627
Mailing Address - Fax:520-626-5009
Practice Address - Street 1:1501 N CAMPBELL AVENUE
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85724
Practice Address - Country:US
Practice Address - Phone:520-626-6627
Practice Address - Fax:520-626-5009
Is Sole Proprietor?:No
Enumeration Date:2006-09-27
Last Update Date:2013-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZRN113958363LN0000X
AZAP2222363LN0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LN0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerNeonatal
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ207375Medicaid
105390Medicare ID - Type Unspecified
Q51719Medicare UPIN